Document o f The World Bank

FOR OFFICIAL USE ONLY

Report No: 35849-MR

PROJECT APPRAISAL DOCUMENT

ON A

PROPOSED CREDIT

IN THE AMOUNT OF SDR 7.0 MILLION (US$ 10.0 MILLION EQUIVALENT)

TO

THE ISLAMIC REPUBLIC OF MAURITANIA

FOR A

HEALTH AND NUTRITION SUPPORT PROJECT

MAY 3,2006

Human Development I1 Africa Region

This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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AfDB AIDS CAS CSM DAF DHR DHS DPCIS DRPSS EU HIPC H N HNSP ICB IDA IEC KAP LIL MDGs M&E MOHSA MTEF NGO NHSAP NNDP ONS POAS PPF PRSP SECF SBD SDR S I L SOE SWAP UM UNFPA UNICEF WHO

CURRENCY EQUIVALENTS Currency unit -1 USD = 263 UM

(Exchange Rate Effective April 2006)

Fiscal Year January 1 to December 31

ABBREVIATIONS AND ACRONYMS African Development Bank Acquired Immune Deficiency Syndrome Country Assistance Strategy Sanitary District of Moughata Directorate of Financial Affairs Directorate of Human Resources Demographic and Health Survey Directorate of Planning, Cooperation and Statistics Regional Health Directorate European Union Highly Indebted and Poor Countries Human Immuno-Deficiciency Virus Health and Nutrition Support Project International Competitive Bidding International Development Association Information, Education and Communication Knowledge, Attitudes and Practice (Survey) Learning and Innovation Loan Millenium Development Goals Monitoring and Evaluation' Ministry of Health and Social Affairs Medium-Term Expenditures Framework Non-Organizational Organization National Health and Social Action Policy National Nutrition Development Policy National Bureau of Statistics Annual Operational Plan Project Preparation Facility Poverty Reduction Strategy Paper State Secretariat for the Promotion of Women Standard Bidding Document Special Drawing Rights Specific Investment Loan Statement of Expenditures Sector Wide Approach Monetary Unit - Ougguiya United Nations Fund for Population Activities United Nations Children's Fund World Health Organization

Banque Africaine de Dkveloppement Syndrome Imrnuno-Deficitaire Acquis Stratkgie d 'Assistance au Pays Circonscription Sanitaire de Moughata Direction des Affaires Financiires Direction des Ressources Humaines EnquZte Dkmographique et de Santi Direction de la Planification,, Coopiration et Information Sanitaire Direction Regionale pour la Promotion Sanitaire et Sociale Union Europeenne Pays Pauvres TrBs Endettks Virus Immuno-Dificitaire Humain Projet d 'Appui a la Santi et Ir l a Nutrition Appel d'Offres Ouvert International Association Internationale de Diveloppement Information, Education et Communication Enquite sur les Connaissances, Attitudes et Pratiques PrZt au Diveloppement des Connaissances et Ci I 'Innovation Objectvs de Dkveloppement du Millknaire Suivi et Evaluation Minist ire de la Santk et des Affaires Sociales Cadre des Dkpenses 6 Moyen-Terme Organ isation Non-Gouverrnemtale Politique Nationale de S a d et d i lct ion Sociale Politique Nationale de Diveloppement de l a Nutrition Office National de la Statistique Plan d 'op i ra t ion Annuel pour le Secteur Micanisme de Financement de la Prkparation des Projets Crkdit de Soutien Ci la Reduction de la Pauvretk Secretariat d'Etat a la Condition Fiminine Documents Types d 'Appel d'Offres Droits de Tirage Spiciaux PrZt d 'Investissement Spkif ique Relevk des Dkpenses Approche Sectorielle Unite Monktaire - Ouguiya Fonds des Nations Unies pour la Population Fonds des Nations Uniespour I'Enfance Organisation Mondiale de la Santk

Vice President: Gobind T. Nankani Acting Country Director: N i l s 0. Tcheyan Acting Sector Manager: William Experton

Task Team Leader: Astrid Helgeland-Lawson

MAURITANIA HEALTH AND NUTRITION SUPPORT PROJECT

(HNSP)

TABLE OF CONTENTS

Page

STRATEGIC CONTEXT AND RATIONALE ............................................................................... 4 A . .................................................................................................... 1 . Country and sector issues 4

2 . 3 .

Rationale for Bank involvement ......................................................................................... 6

Higher level objectives to which the project contributes .................................................... 8

PROJECT DESCRIPTION ............................................................................................................... 8 B . 1 . 2 Program objective 9

3 . Project development objective and key indicators ............................................................ 10

4 . Project components ........................................................................................................... 11

5 . Lessons learned and reflected in the project design .......................................................... 14

6 . Alternatives considered and reasons for rejection ............................................................ 16

C . IMPLEMENTATION ...................................................................................................................... 17

Partnership arrangements .................................................................................................. 17

Lending instrument ............................................................................................................. 8

. ...............................................................................................................

1 . 2 . 3. Monitoring and evaluation o f outcomes/results ................................................................ 19

4 . Sustainability ..................................................................................................................... 20

5 . Critical r isks and possible controversial aspects ............................................................... 21

6 . Loadcredit conditions and covenants ............................................................................... 22

APPRAISAL SUMMARY ............................................................................................................... 23

Institutional and implementation arrangements ................................................................ 17

* . .

D . 1 . 2 . 3 . 4 . 5 . 6 . 7 .

Economic and financial analyses ...................................................................................... 23

Technical ........................................................................................................................... 24

Fiduciary ........................................................................................................................... 25

Social ................................................................................................................................. 25

Environment ...................................................................................................................... 26

Safeguard policies ............................................................................................................. 27

Policy Exceptions and Readiness ...................................................................................... 27

Annex 1: Country and Sector Background ............................................................................................. 28

Annex 2: Ma jor Related Projects Financed by the Bank and other Agencies ..................................... 35

Annex 3: Resul ts Framework and Monitoring ....................................................................................... 36

Annex 4: Detailed Project Description .................................................................................................... 40

Annex 5: Proposed financing .................................................................................................................... 47

Annex 6: Implementation Arrangements ................................................................................................ 48

Annex 7: Financial Management and Disbursement Arrangements ................................................... 52

Annex 8: Procurement Arrangements .................................................................................................... 59

Annex 9: Economic and Financial Analysis ............................................................................................ 64

Annex 10: Safeguard Policy Issues .......................................................................................................... 79

Annex 11: Project Preparation and Supervision .................................................................................... 80

Annex 12: Documents in the Project F i l e ................................................................................................ 81

Annex 13: Statement of Loans and Credits ............................................................................................ 83

Annex 14: Country at a Glance ................................................................................................................ 84

MAP No . IBRD 33445

MAURITANIA

ASSOCIATION Total:

HEALTH AND NUTRITION SUPPORT PROJECT

4.00 7.00 11.00

PROJECT APPRAISAL DOCUMENT

AFRICA

AFTH2

Date: M a y 3,2006 Acting Country Director: N i l s 0. Tcheyan Acting Sector Manager: Wil l iam Experton

Project ID: PO94278

Lending Instrument: Specific Investment Loan

Team Leader: Astrid Helgeland-Lawson Sectors: Health (80%);

Themes: Other human development (P) Environmental screening category: Partial Assessment

Other social services (20%)

[ ] Loan [XI Credit [ ] Grant [ ] Guarantee [ ] Other:

For Loans/Credits/Others: Total Bank financing (US$m.): 10.00 equivalent

~~

Borrower: Minister o f Economic Affairs and Development Ministry o f Economic Affairs and Development B.P. 238 Nouakchott, Mauritania Fax: (222) 525 4617

Responsible Agency: (i) (ii) Nouakchott, Mauritania

Ministry o f Health and Social Affairs State Secretariat for the Promotion o f Women

1

Estimated disbursements (Bank FY/US$m) FY Annual Cumulative

7 8 9 10 0 0 0 0 0 2.00 4.00 3 .OO 1 .oo 0.00 0.00 0.00 0.00 0.00 2.00 6.00 9.00 10.00 0.00 0.00 0.00 0.00 0.00

Expected effectiveness date: October 2, 2006 Expected closing date: December 3 1, 2009

[ ]Yes [XINO Does the project depart from the CAS in content or other significant respects? Re$ PAD A.3 Does the project require any exceptions from Bank policies? Re$ PAD D. 7 Have these been approved by Bank management? I s approval for any policy exception sought from the Board? [ ]Yes [ IN0

[XIYes [ ] N o

[XIYes [ ] N o

Does the project include any critical r isks rated “substantial” or “high”? Re$ PAD C.5 Does the project meet the Regional criteria for readiness for implementation? Re$ PAD D.7

Project development objective Re$ PAD B.2, Technical Annex 3 The HNSP overall objective i s to strengthen the health system and i t s capacity to improve the health and nutrition status o f the population, notably o f women, children, and the poor, as it will support the implementation o f the Government Program for the health and nutrition sectors during the period 2006- 2008.

Project description [one-sentence summary of each component] Re$ PAD B.3.a, Technical Annex 4 1) Further develop human resources and improve their geographical distribution; 2) Ensure adequate sector financing and equitable allocation o f resources for the poor and for underserved geographical areas; 3) Improve health sector management to raise efficiency; 4)Improve the accessibility to quality and affordable health services in underserved areas; 5) Enhance and expand community-based communications for improved nutrition.

Which safeguard policies are triggered, if any? Re$ PAD D. 6, Technical Annex 10 The project has triggered OP 4.01 Environmental Assessment and OP 4.12 Involuntary Resettlement due to potential negative environmental and social impacts related to the constructiodrehabilitation o f health centers and health posts, and ineffective medical waste management. The safeguard screening category i s S2; and the environmental screening category i s B. T o address potential negative impacts consistent with the requirements o f these safeguard policies, the project has prepared an ESMF and a RPF. In addition to describing the environmental and social screening process, the ESMF makes recommendations regarding capacity building needs to ensure i t s effective implementation, and consultations with potentially affected persons as part o f the screening process that will take place at the time construction and rehabilitation plans are prepared. To address issues related to medical waste management at the health centers and health posts to be constructed andor rehabilitated, the Government draws on the National Medical Waste Management Plan and will implement relevant activities (training, segregation, public awareness campaigns). This plan, plus a summary o f the project objectives and medical waste management provisions, as well as the ESMF and the RPF has been disclosed in Mauritania and at the Bank’s Infoshop prior to appraisal.

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Significant, non-standard conditions, if any, for: None

Board presentation: None

Loadcredit effectiveness: Init ial deposit o f the Counterpart Funds in the Project Account to cover the f i rst six months o f project

expenditures Recruitment o f qualified external auditors

Covenants applicable to project implementation: Progress reports o f the Plan o f Action to be prepared by the MOHSA on a semiannual basis An annual review report o f the Action Plan must be submitted to IDA one month before the annual

review takes place

3

A. STRATEGIC CONTEXT AND RATIONALE

1. Country and sector issues

Political situation and World Bank relation: On August 3, 2005 a bloodless coup took place in Mauritania which ousted the Mauritanian President Taya. Subsequently the Mi l i tary Council for Justice and Democracy formed a transitional Government headed by Colonel Ely Ould Mohamed Vall. The transitional government announced that it would step down within two years after national approval o f a new constitution and parliamentary and presidential elections. The new Government also committed itself to focus on improving: (i) the judicial system, with a view to establishing a fairer system for individuals and a more attractive investment climate for businesses; and (ii) governance, in particular by deepening public finance reforms. After the coup, the Wor ld Bank decided not to suspend disbursements but to put new operations on hold until there were clear signs from the government on i t s willingness to implement their new commitments and that the international community would also indicate their engagement with the transitional government. Since then, the government has developed a road map on governance addressing former problematic issues such as transparency in managing the o i l sector. I t normalized the relationship with the IMF, and committed to deepen public finance reforms and modernize the administration which will be supported by an upcoming IDA credit. The government i s also in the process o f developing a new PRSP. In December 2005 the Bank reassessed i t s relationship with the new government as the international community signaled i t s willingness to re-engage with Mauritania. Bank senior management then decided to normalize Bank relations and actively worked on this operation as wel l as a Public Sector Capacity Building project.

Health and nutrition status in Mauritania: Since the country’s independence in 1960, Mauritania has undergone important transformations and from a traditionally nomadic society o f the past it became a country characterized today by a higher pace o f urbanization. Of the 2.7 mi l l ion inhabitants, some 1.8 mi l l ion l ive in urban centers, including 600,000 in Nouakchott, the capital city. However, o f the vast surface o f the country (1,03 mi l l ion sq. km) over 80% o f the land i s desert (only the southern areas o f the country support rain-fed vegetation). The very l o w density o f the population living in rural areas (on an average there are 2.4 inhabitants per sq. km), incomplete road and communication systems and poverty generate important problems and impact on the health and nutrition status and the performance o f the health delivery system. About 46 percent o f the population lives below the poverty line, only 37 percent o f the population have access to safe water and 77 percent to health services. With an annual gross national income per capita o f only US$430, Mauritania remains one o f the poorest countries in Africa.

Most health status indicators in Mauritania have improved during the last decade and compare favorably with Sub-Saharan Africa countries. For instance, between 1988 and 2000 the under-5 mortality rate declined from 182 to 1 16 per 1,000 l ive births, infant mortality rate diminished f rom 1 18 to 74 per 1,000 l ive births, and maternal mortality decreased f rom 930 to an estimated 747 per 100,000 l ive births (Demographic and Health Survey (DHS) 2000-Ol), contributing to a l i fe expectancy o f 56 years in 2002 (from 53 years in 1999). While the total fertility rate also declined fi-om 6.2 percent in the eighties to 4.6 percent in 2000, the population growth remained high at around 2.5 percent. Conversely, chronic malnutrition rates have stagnated between 1988 and 2001 (DHS), and remain a serious problem in rural areas among the poorest and the very young (0-3 years) who are the most vulnerable. Nearly one third o f children suffer from this condition. In addition, acute malnutrition, or wasting, at 13 percent constitutes a serious health problem (see also Annex 1).

The health delivery system has been strengthened during the last decade and access to services and the geographical distribution o f health personnel have improved. For instance, in 2003, chi ld immunization rates reached 73 percent, 63 percent o f deliveries were assisted by a health provider and the number o f

4

consultations per inhabitant increased to 0.3-0.4 per year while hospital utilizations rates remained stationary at around 60 percent. These figures demonstrate improvement but also modest performance. Notwithstanding this progress, there i s need to further improve the sector’s performance.

M a i n health and nutrit ion sector issues are as follows:

Insufficient and inequitable access, problems with affordability and utilization of health and nutrition services. Even as access to health services has increased, 23 percent o f the population must travel more than five kilometers to reach a health center or a health post, and 10 percent must travel more than ten kilometers to reach the nearest health facility. This, in a country l ike Mauritania, i s more dramatic than elsewhere because of climatic and geographical conditions, the critical state o f roads and the cost of transportation. Low accessibility i s among the main causes o f under utilization o f health services in rural areas, in particular in l o w population-density areas (such as the central and northern regions). Other major contributors to underutilization o f inpatient services and low attendance o f outpatient facilities are affordability, in particular for the rural population, and health provider’s behavior when discharging services to the poor population. The government intends to update the “Infrastructure development plan” and, by developing outreach community-based services, to reduce the existing disparities in geographical accessibility thus targeting the poor and other underserved groups in remote areas. Also, Government’s policy aims to better involve the private sector in the delivery o f basic services especially in urban cities and to motivate providers.

Inadequate financing and inequitable resource allocation. The funding o f the health and nutrition sectors remains low compared to the cost o f reasonably good service provision and makes the achievement o f the Mil lennium Development Goals (MDGs) questionable. Resource allocation to regions and facilities i s not l inked to performance nor does it pay sufficient attention to the needs o f the poorest regions. The Government has updated the Medium-Term Expenditures Framework (MTEF) for the period 2005-2007 in accordance with sector budget requirements and poverty reduction objectives. Emphasis was given to the quality and equity o f the sector spending, better budget management and harmonization of donors’ procedures. Government has adopted a revised cost recovery system and has taken steps towards the implementation o f mutual funds and subsidies targeting the poor and pregnant women.

Shortages of skilled of health care providers and low motivation. There has been progress in human resources development (documented in a recent Health Personnel Census, 2004) e.g., a larger proportion of providers i s now working in regions. However, shortages o f qualified and motivated health and social workers along with imbalances in the skill-mix and uneven geographical deployment remain among the key factors affecting the quality and utilization o f services provided by the public sector. Ineffective management, training and supervision exacerbate the lack o f responsiveness o f the system to the health needs o f the population. To improve service provision to the rural population, the government i s implementing innovative policy and reform measures (including incentives to the staff to relocate and work in rural areas) that will need to be further pursued in the years to come. Skilled nutrition staff in the health sector i s very limited. Moreover, community nutrit ion workers, who received some training under the earlier project, are relatively few and more intensive training i s urgently needed.

Inadequate drug quality and supply: Drug shortages continue to persist in health facilities and the capacity o f the drug procurement and distribution system needs further strengthening. In addition, there are problems with drug quality, which affect both the public and the many private pharmacies of the country. The recently adopted pharmaceutical policy, which includes a new registration system and more capacity to enforce regulation for drug quality control, ought to be thoroughly and promptly implemented to reduce the circulation o f l ow quality and counterfeit drugs.

5

Insufficient institutional capacity. The Ministry o f Health and Social Affairs (MOHSA) i s not adequately staffed and equipped to provide efficient stewardship for the implementation o f the Health Sector Development Plan and, generally speaking, to carry out i t s day to day management functions. Although the regional health directorates (DRPSS) have been strengthened, this does not suffice to effect adequate decentralization. To obtain more cooperation from stakeholders also require immediate and sustained attention. Similarly, the State Secretariat for the Promotion o f Women [Secrktariat d’Etat i2 la Condition Fkminine (SECF)] i s not sufficiently decentralized. In addition, the SECF capacity to develop nutrit ion policies, implement nutrition interventions and deliver services i s inadequate. Program execution in the sector i s slowed down by the rapid turn over o f staff holding key positions and by weaknesses in financial management and procurement. Issues such as the collection o f information and quality data for monitoring and evaluation are among the key elements that s t i l l require detailed analysis, planning and support. Coordination between MOHSA and SECF, which share the mandate for malnutrition prevention and reduction, has been problematic over the past years.

Poor management of health and nutrition service provision. Increased resource allocations have not translated into increased performance o f many o f the priority health programs or interventions (such as tuberculosis, malaria, reproductive health, infectious disease control, maternal and chi ld health and nutrition) because of weak management, poor intersectoral collaboration (in matters such as water, sanitation, nutrition), insufficient community participation and lack o f emphasis on demand creation for preventive services. The new health sector policy seeks to: (i) firther decentralize the management o f priority public health programs to the DRPSSs; (ii) broaden the role o f health committees to include prevention, hygiene and sanitation; (iii) lay emphasis on IEC and other activities to induce behavior changes; and (iv) improve intersectoral collaboration. The new National Nutrit ion Policy calls for a stronger communication program to change behavior and promote better feeding practices.

Inadequate commitment to nutrition: At the highest polit ical levels, progress has been made in raising the awareness o f nutrition as a development issue, witness the development o f a national nutrition policy and the acceleration o f nutrition interventions over the last five years. However, nutrit ion i s s t i l l not seen as a cause o f poverty and an obstacle to economic development, which for these reasons i s worthy o f investment. In addition, nutrition programs s t i l l have very l o w coverage, al l o f which imply that much more remains to be done in this domain.

2. Rationale for Bank involvement

Over the past decade, the Government has demonstrated i t s commitment to poverty reduction. It has undertaken a broad macroeconomic, structural and social reform program and, since early 2001, has implemented satisfactorily the Mauritania Poverty Reduction Strategy Paper (PRSP). Two PRSP progress reports showed that MDGs remain high on the government’s -agenda. But the said reports also pointed to the fact that under current policies and with present financial flows, the country i s highly unlikely to reach the health and nutrition related MDGs. Three years o f drought followed by the locust invasion may also have hindered the achievements o f targets. Between 1998 and 2003, other donor funds contribution as a share in health financing declined from 55 % o f the total health budget to 26 %. Additionally, one donor has decided to redirect i t s aid to other sectors and another will channel i t s aid through budget support, One important reason was the availability o f HIPC resources. Maintaining donor funding to the health sector is, therefore, critical. On the positive side, o i l reserve exploitation might generate resources in mid- term.

Experience from other countries in Africa and elsewhere has demonstrated that rapid improvement o f national wealth (as the one anticipated in Mauritania due to the exploitation o f o i l reserves) i s not necessarily followed by a more equitable distribution o f resources and, more often than not, increases the gap between the r ich and the poor. This is l ikely to also happen in Mauritania and provides the rationale

6

for continuing the support to health and other social services with emphasis on the accessibility and affordability o f these services for the poor.

The main objective o f the Country Assistance Strategy (CAS) for FY03-05 i s to support the Government in the implementation o f i t s poverty reduction strategy. The third CAS pil lar i s particularly relevant to the health and nutrit ion sectors: the development o f human resources and the expansion o f the access to basic infrastructure and services. The proposed Health and Nutrit ion Support Project (HNSP) would be consistent with a l l the objectives o f the CAS, and especially relevant to human resource development, increased access o f the poor to basic services, and institutional development based o n good governance.

The Government and IDA have been partners in the health sector in Mauritania since the early 90s. The Bank’s assistance consisted of: (i) the Health and Population Project (FY92); (ii) the Health Sector Investment Project (FY98); (iii) the Nutricom Project which was a Nutrit ion Learning and Innovation Loan (LIL) (FY99); and (iv) the multi-sector HIV/AIDS project (FY03). The Health and Population Project and the Health Sector Investment Project had satisfactory outcomes and demonstrated government’s willingness and ability to address complex sectoral and developmental issues, while the Nutr i t ion LIL resulted in important lessons that have been incorporated in the project design. The adoption o f a sector-wide approach (SWAP) for the implementation o f the Health Sector Investment Project as early as in 1998 i s another evidence o f Government’s commitment. Notwithstanding the fact that there was n o pooling o f resources and common implementation arrangements, the sector-wide approach used by the health sector in Mauritania was successful as it substantially contributed to the: (i) strengthening o f the collaboration with donors and among stakeholders, (ii) development o f an effective planning and evaluation mechanism by means o f which donor activities became part o f sector-wide annual operational plans, (iii) decentralization o f decision making to regions and (iv) strengthening o f the capacity in the sector and, to some extent, to the pursuance o f reform objectives such as the ones on drug procurement (an autonomous Drug Procurement Agency was created), health provider re-deployment and motivation system, emphasis on accessibility and affordability o f basic health services, etc. Therefore the proposed credit would be fully justified since it will build on past achievements and, also, will help pursue the reform process in the sector.

The n o w closed Nutricom project, which was implemented between 1999 and 2005, piloted a community- based approach to reducing malnutrition in both urban and rural areas. The experience with the LE showed that the country’s capacity to develop nutrition policies and implement complex interventions was overestimated. Although much has been done to improve the capacity, i t remains weak and inadequate for community-based growth promotion interventions to be scaled up under this new project. Community-based growth promotion i s a managerially complex intervention that requires a high level o f supervision and motivation. On the other hand, national awareness o f nutrition being a development problem and political commitment to engage in the fight against malnutrition, have increased. A National Nutrit ion Policy has been approved and i s being translated into programs in 2005. However, malnutrition rates remain very high in Mauritania and the focus o f this project being on nutrit ion i s in response to a request from the government to continue addressing the issue.

Hence, the proposed HNSP i s fully consistent with the health and nutrition needs o f the population o f the country as it would support the implementation o f the National Health and Social Action Policy 2005- 2015 (NHSAP) , and the National Nutrit ion Development Policy 2005-2010 (NNDP). The Bank’s assistance to the country remains, therefore, essential to foster progress in the health and nutrit ion sectors and sustain efforts to provide equitable services to the under-served.

7

3. Higher level objectives to which the project contributes

The Government’s Program for the health and nutrition sectors i s clearly stated in the recently updated National Health and Social Action Policy (NHSAP) and the newly adopted National Nutr i t ion Development Pol icy (NNDP). These policies, both developed through broad participatory processes, have a strong poverty focus and aim at accelerating the achievement o f (i) more demanding health and nutrition outcomes, (ii) sector reform objectives and, ultimately, (iii) PRSP and MDGs targets by the year 20 15. The proposed HNSP would provide support to the implementation o f these far-reaching policies and targets.

B. PROJECT DESCRIPTION

1. Lending instrument

The Health and Nutr i t ion Support Project (HNSP) would be financed through a Specific Investment Loan (SIL) o f US$lO.O mi l l ion over a 3-year period (2007-2009) to support the Government’s Program for the health and nutrit ion sectors. The credit would assure the completion o f a range o f activities started under the Health Sector Investment Project (closed on December 31, 2004) and use similar implementation arrangements being a follow-up project. The lessons learned f rom the Nutricom project (closed on April 3 1, 2005) would also feed into the new design. Notwithstanding these similarities, HNSP’s main thrust would be to support (i) measures to strengthen sector performance and institutional capacity (in the MOHSA and the SECF, centrally and in regions) and (ii) selected key areas o f concern to improve health and nutrition outcomes thus contributing to the achievement o f MDGs and poverty reduction objectives.

The proposed project would be an integral part o f the Government’s health and nutrition policies and would be implemented by the MOHSA (the health package described in component 4.1-4.4, section 4) and the SECF (the community nutrition activities described in component 4.5, section 4) in a collaborative and transparent manner with bilateral and multilateral donors and UN technical agencies (French Development Agency, Spanish Cooperation, African Development Bank (AfDB), United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), Wor ld Health Organization (WHO)).

The part o f the operation to be implemented by M O H S A (80%) would be conceived as a sector-wide operation (SWAP) and would be guided by the following principles: 0 Donor and government interventions will be (a) supportive to the agreed upon sector policy (National

Health and Social Action Policy (2005-2015) and (b) consistent with the MTEF; 0 Joint (Government and al l donors) annual working sessions to review progress and to develop sector-

wide work plans will be carried out; Key performance indicators will be agreed upon and will serve to monitor progress and evaluate outputs and outcomes; and

0 The SWAP will not entail pooling o f funds and harmonized procedures. However, as capacity improves, common procedures and implementation mechanisms will progressively be established in a move towards future program supporthudget support.

The activities to be implemented by SECF (20%) would be based on: 0 An annual SECF work plan supporting the National Nutr i t ion Development Policy (2005-2015);

Key performance indicators that will be agreed upon and will serve to monitor progress and evaluate output and outcomes; A sector-wide approach would not be put in place for the community nutrition component for practical reasons (the SECF i s not used to implement such an approach, and the size o f the

8

community development component would not justify the additional resources needed in order to implement such an approach). However, for activities pertaining to the community nutrition component, the SECF will participate and contribute to the M O H S A annual sector review.

IDA funds would b e allocated on an annual basis based on the following process: Yearly, M O H S A will evaluate the implementation o f the Annual Operational Plan (POAS) of the previous year and develop an operational plan for the upcoming year (based on regional and departmental submissions); Included in the annual operational plan for the health sector will be the Annual Nutr i t ion Action Plan (PAAN) for the Nutrit ion interventions, which will be prepared by the SECF on the basis o f annual reviews o f the progress in implementing community-based nutrition activities; The POAS will be discussed and approved by donors, other stakeholders, and IDA; The POAS and the P A A N set o f activities to be funded from the IDA credit and the related procurement and disbursement plans will be submitted to IDA for non-objection; and Due to the short time-span o f the proposed operation (three years) and based on the lessons learned from other IDA supported activities in the sector, IDA support to c iv i l works will be identified for the entire 3-year period and would be formalized into a Procurement and Disbursement Plan for c iv i l works. Civil works being a small disbursement category in this project will constitute less than 25% o f the total credit.

The following will guide the overall execution o f the program: 0

0

Resources will be allocated with preference to the poorest regions; Priority will be given to improving the functioning o f existing health facilities, i.e. personnel and other necessary support would be provided with priority to facilities whose performance needs improvement; An update o f the infrastructure development plan, including (a) a review o f the situation o f health facilities that are not operating (sewices de santk non-fonctionnels) and (b) a review o f human resources in the sector and regions, will be conducted and will init ially be financed fi-om the PPF. These documents will be used in the POAS development process; The Government will implement specific measures to render drugs and services affordable, facilitate the access o f the poor and raise the demand for health services with emphasis on prevention. The implementation and observance o f these thrusts will be monitored systematically; Communication, not weighing, i s the essential component o f the community-based nutrition strategy, implying that activities and services are not solely center-based but more geared towards coverage and impact; and The community nutrition strategy will be expanded to two additional Regions.

0

0

0

0

2. Program objective

The overall objective o f the Government Program i s to contribute to the improvement o f the health and nutrition status o f the population in general, notably o f women, children, and the poor, and by that accelerate progress towards the health and nutrition related MDG targets. The Government Program i s stated in the recently updated National Health and Social Action Policy (2005-2015) and a newly adopted National Nutrit ion Development Policy (2005-2010). The HNSP would be a support project to assist the Government to implement these policies.

The following strategies are outlined in the Government’s policies as well as in the MTEF (2005-2007): (i) human resources development with emphasis on sk i l l s and reasonable geographical distribution; (ii) expansion o f coverage and improvement o f quality and utilization o f health and nutrition services; (iii) availability o f quality drugs at affordable prices; (iv) raising the demand for primary health services with

emphasis on prevention; (v) social action and creation o f an environment conducive to health and nutrition; (vi) capacity building to improve performance and use resources more efficiently; (vii) provision o f adequate financial resources; and (viii) intersectoral collaboration and broader involvement o f stakeholders.

# Key Project Performance Indicators

1 Number o f intersectoral coordination meetings for the

3. Project development objective and key indicators

Current Year 1 Y e a r 2 Y e a r 3

0 3 3 3

3.1. Project Development Objective The HNSP overall objective i s to strengthen the health system and i ts capacity to improve the health and nutrit ion status o f the population, notably o f women, children, and the poor, as it will support the implementation o f the Government Program for the health and nutrition sectors during the period 2006- 2008.

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HNSP would have the following more specific objectives: (i) improve access to basic health services in underserved areas; (ii) improve the equitable allocation o f resources to underserved areas; (iii) strengthen the health sector management to raise efficiency; and (iv) enhance and expand community-based communications for improved nutrition.

Progress towards the achievement o f these specific objectives would be monitored during HNSP implementation.

- management o f human resources for health Number o f MOHSA integrated supervisions with HR 0 2 2 2

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Hodh e l Gharbi 48% 54% Assaba 63% 65% Guidimaka 73% 75%

4. Project components

60% 66% 67% 69% 77% 79%

HNSP would provide support to priority activities for which there i s a financial gap, provided that they are consistent with the sector policy and there i s agreement on their relevance. However, based on lessons learned from past operations, i t was deemed necessary to pre-identify the entire set o f c iv i l works that would be supported fi-om the credit. Also, the implementation o f the Health Sector Investment Project demonstrated that a certain focus on key issues i s necessary, thus making possible to evaluate outputs in a more specific manner. Focusing on key issues would also al low a more substantial contribution to the achievement o f MDGs, which i s the fundamental priority o f the country. Lastly, and based again on past

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experience in Mauritania and elsewhere, i t was deemed useful to retain a certain flexibil i ty in financing, to monitor progress periodically and to plan in a transparent manner depending upon the ever evolving situation in the sector (in terms of needs, financing and implementation capacity). As a consequence of the above features, activities to receive financial support from the credit would fal l into two categories: (i) Support pertaining to all other disbursement categories would be discussed and agreed upon on an annual basis using the annual progress review and operational planning process already in place; and (ii) Civil works wou ld be launched during the first year o f the operation, and. The HNSP funding would remain flexible because part o f the credit will be allocated on an annual basis and also because the totality of IDA funded activities will be reviewed every year and adjustments made when and if needed.

The proposed HNSP would provide support focusing on the areas identified below. The M O H S A would implement the health package described in paragraphs 4.1-4.4 and SECF would implement the community-based nutrit ion interventions as described in paragraph 4.5.

4.1 Further develop human resources and improve their geographical distribution (US$2.0 million). The project would support activities to (i) strengthen the sector capacity to manage human resources; (ii) improve inter and intra-sectoral coordination for better management o f human resources; and (iii) improve management and content o f training programs, including formative supervision.

e Professionalize the Directorate of Human Resources at all levels through: (i) strengthening human and material capacities o f the DHR in order to fulfill i t s mandate; (ii) maintaining a human resources management system that uses a forecasting and preventive approach contributing to an improved knowledge and a better distribution o f available staff (technical and administrative), in accordance with revised staffing norms, expressed needs, and available resources. e Improve coordinating mechanisms for improved human resources management through: (i) establishing a network system for information sharing between the DHR an the DRPSS on staffing, needs, etc.; (ii) strengthening the capacities to manage human resources at the level o f the DRPSS; (iii) strengthening DHR capacity to participate in the public administration reforms within the M O H S A and those led by other ministries; (iv) improving coordination between the DHR/MOHSA and other sectors involved in human resources management; and (v) pi lot ing an accountability system for health care providers co-managed with the communities. e Improve the management and content of pre-services and in-service training, and on-the- job training through: (i) improving the coordination with training institutes (ENPS, INSM), while exploring possibilities o f sub-contracting with training institutes located in the sub-region; (ii) improving efficiency o f the DHR to manage training abroad and maintain personal f i le accordingly; (iii) revising curricula and training programs to reflect the national health pol icy orientation such as quality-assurance (approach centered on the patient), environmental management, training o f trainers; and (iv) improving integrated formative supervision from the central to the regional level and from the regional to the decentralized level.

4.2 Ensure adequate sector financing and equitable allocation o f resources for the poor and for underserved geographical areas (US%1.5 million). The project would support activities (i) to improve the existing process and methods for mobil izing the different sources o f sector financing and for allocating them more equitably; and (ii) to strengthen measures to ensure financial accessibility to health services, increase utilization o f services by the poorest and most vulnerable, and to rationalize the existing cost recovery system.

e Mobilization and allocation of sector financial resources. T o further support MOHSA's progress since 2003 in improving the annual budget preparation process, the HNSP will provide technical and financial assistance to strengthen ministry capacity to: (i) prepare the annual updates o f the medium-term expenditure framework (MTEF) for the sector; (ii) establish criteria for distribution

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o f budget and for allocations by level o f care, region, type o f expenditure, etc.; and (iii) organize annual sectoral expenditure reviews. The project wil l also contribute to the preparatory work necessary to establish national health accounts (NHA).

needs o f the sector, the stabilizing of available resources for health, and the relatively l o w level o f budgeted health expenditures over the last three years, the HNSP will support efforts: (i) to subsidize essential health services for the poor and other targeted populations; (ii) to organize payment o f health services for the poorest and most vulnerable populations who are unable to afford subsidized services; and (iii) to help those populations interested in and able to establish alternative financing systems (mutuelles) at community level to share risks. In addition, the HNSP will provide support for strengthening the cost recovery system, including revising the regulatory basis for charging and collecting monies and training facility-level management committees.

0 Financial access of the population to health services. Given the increasing financial

4.3 Improve health sector management to raise efficiency (US$l.O million). This component would finance activities: (i) to promote the sector-wide approach; and (ii) to develop the management capacity o f health sector personnel at al l levels.

0 Developing the sector-wide approach. Initiated in 1998 with support from the HSSP, the sector-wide process has advanced, and HNSP would provide support to MOH in the process o f formulating a memorandum of understanding clearly establishing the objectives, roles and relationships o f the collaboration. 0 Strengthening of sector management capabilities. HNSP would concentrate especially on: (i) enhanced coordination o f the planning and budgeting process; (ii) increased budget execution through more efficient organization o f the procurement process and improved financial management; and (iii) development o f measures and modalities for monitoring and evaluating the programmatic interventions. 0 Monitoring and evaluation. HNSP would monitor and evaluate progress within the overall context of: (i) the poverty reduction strategy through achievement o f the MDGs pertaining to health; (ii) the development o f a consolidated sectoral program with common measures and procedures for supervising, monitoring, and evaluating results; et (iii) the regular submission o f project reports on physical and financial results as well as periodic supervision o f HNSP's key performance indicators.

4.4 Improve the accessibility to quality and affordable health services in underserved areas (US$3.5 million). This component include activities to (i) improve access to and quality o f basic health services, (ii) raise demand for services, and (iii) strengthening o f the monitoring and evaluation o f the quality o f the services.

0 Construction o f approximately 13 health posts and 1 health center in areas o f low accessibility to public or private health services and rehabilitation o f selected primary health facilities. The sites o f these facilities would be chosen based on accessibility criteria, estimated number o f population in the catchment area, possible existence o f specific health problems, etc.. The facilities will benefit from maintenance and equipping, including the provision o f equipment to ensure effective medical waste management. 0 Activities to improve access to and quality of services by: (i) the strengthening o f outreach activities from health posts, and the revival o f the community approach in order to ensure improved access to preventive child, maternal and nutrition interventions for the population in hard- to-reach areas; and (ii) the improvement o f the availability o f drugs. 0 Activities to raise the demand for health and nutrition services, with emphasis on prevention, and to induce behavioral changes conducive to health and nutritional improvements; and

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increase community participation in the management o f health services and to render health providers more responsive to the needs of the underserved populations.

through the enhancement o f the integrated formative supervision, and the revitalization of the monitoring system of the primary health care facilities.

extension o f the Integrated Approach to Childhood Illness (IMCI); (ii) reduction o f maternal mortality by the improvement of the availability, the quality and the utilization o f emergency obstetrical and neonatal care; and (iii) decrease in the incidence o f schistosomiasis’.

0 Strengthening of the monitoring and evaluation of the quality of the services provided

Strategies to be supported would include: (i) reduction o f chi ld mortality primarily by the 0

4.5 Enhance and expand community-based communications for improved nutrition (US$2.0 million). This component would finance activities to: (i) develop and implement a community-based nutrition communication strategy, (ii) improve access to basic essential health and nutrition services; (iii) support the application of the salt iodization law in close collaboration with UNICEF; and (iv) strengthen the capacity o f the SECF to plan, monitor and evaluate nutrit ion communication program implementation. This will be achieved using community mobilization strategies, training o f polyvalent community agents, and interpersonal communication strategies supported by group and mass communication strategies. Basic essential health and nutrition services refer to essential services that can be provided by trained community agents, e.g., micronutrient supplementation, de-worming, and distribution o f bed-nets. Messages about micronutrients would typically be included under the communications program to mobilize the community and raise awareness about the importance. The MOH and the SECF, by means o f a memorandum o f understanding, will coordinate efforts and collaborate on community health and nutrition issues.

5. Lessons learned and reflected in the project design

The proposed project would be the fourth IDA-financed project in the health and nutrition sectors in Mauritania and would be the f i rst operation simultaneously supporting health and nutrition, and implemented by two partners (ie., MOHSA and SECF). Lessons learned from other projects, notably in Mauritania, and reflected into HNSP design include:

Project Management. With regard to management, a project management unit can be very effective, but might not necessarily help develop the implementation agency’s capacity. As a consequence, at project closing, unless the project unit’s staff become c iv i l servants, part o f the investment i s lost. The M O H S A has successfully drawn from this lesson and the Health Sector Investment Project had already been implemented by M O H S A staff. In the case o f the HNSP, the Government opted again for a project to be implemented by the health and nutrition sector administrations, and undertook to strengthen the capacity o f key MOHSA and SECF departments to ascertain adequate project implementation.

0 Monitoring and evaluation indicators. Agreeing on a set o f monitoring and evaluation indicators does not suffice, if at mid-term and at project closing comparable and reliable information cannot be made available. Taking into account this observation, the HNSP will provide support to strengthen the Management Information System and improve data quality and reporting. The HNSP will also contribute to the financing o f a DHS, which would provide data to document trends since the last DHS (also conducted with IDA support in 2000/2001). Finally, a beneficiary assessment will be carried out in the project’s preparation phase.

‘ Activities for control o f other endemic diseases already receive adequate financing from other sources such as The Global Fund for malaria and tuberculosis, or GAVI for vaccination, as we l l as UNICEF, WHO and the Wor ld Bank M A P for HIV/AIDS. However, if needed, these areas would also b e eligible for funding f rom the credit.

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0 Cost Recovery provides much needed additional resources to the facility that raised the money but, in a poor country such Mauritania, could (i) deter the poor from trying to seek care and (ii) constitute a disincentive for the health providers to dispense preventive services (which generally remain free of charge). HNSP will, therefore, support a review o f current cost recovery practices in Mauritania and, based on this review, the generalization o f those best practices which include adequate measures to render services affordable to the poor (such as subsidies, exemption from payment, community based solidarity mechanisms and pre-payment schemes (mutuelles villagoises).

0 Role o f Women. The successful collaboration with the SECF in Nutricom demonstrated once more that women p lay a major role in health status improvement and in economic growth. It also demonstrated that in Mauritania, as well as elsewhere, they connect easily with the rural population and the underserved groups. Therefore, the HNSP would consistently seek ways to directly involve women and i ts entire nutrit ion part i s entrusted to the SECF.

0 Community Involvement. Community involvement i s a major success-factor in many operations and this was also demonstrated throughout several projects and, in Mauritania, very specifically through the Health Sector Investment and Nutricom Projects. Therefore, the HNSP will further pursue community involvement, which will take a larger dimension due, among others, to the stress on decentralization and responsiveness to population needs that characterizes the project.

0 A sector-wide approach, when feasible, has considerable advantages over a traditional investment project. The Government i s in the driver's seat, i s in charge o f implementing and evaluating activities that are part o f i t s own policy, and coordinates donors' contributions. Costly duplications could be avoided and the additional time spent for reaching consensus among stakeholders i s a good investment for motivating partners, building up capacity and ownership. Learning from the experience gained with the previous Health Sector Investment Project, the proposed project will also be designed as a SWAP. Moreover, the HNSP will capitalize on the use o f the annual review and planning process for continuously monitoring progress and planning, and will continue to relay on an open and transparent collaboration with donors and NGOs. However, the Health Sector Investment Project also demonstrated some shortcomings such as the fact that IDA financing was distributed to too many minute activities (all useful but dispersed in a way that precluded the identification of tangible outcome changes). In order to avoid a relapse into this situation and to better prioritize, the HNSP design includes a focus on five project components that address key sectoral issues that may prevent the achievement o f the policy objectives and MDGs.

0 The Heavily Indebted and Poor Countries (HIPC) Initiative. The Heavily Indebted and Poor Countries (HIPC) initiative has made a strong contribution to addressing key issues under the health development program. It helped put health issues at the center o f the policy dialogue between Mauritania and the Bank. It gave a new impetus for re-launching the immunization program, and provided additional resources to the health sector, some of which were used to give hardship allowances to the staff posted outside the capital city. Further to this observation, i t i s intended to continue to pursue both avenues (HIPC and HNSP) and use the CAS and the country team discussions for coordination and support. The PRSP highlighted the malnutrition problem as a development problem in Mauritania, which helped add the nutrition sector on the development agenda. The continuation o f investment in nutrit ion i s a direct result o f the attention it was given in the PRSP.

0 Supply of services does not necessarily increase utilization rates. The Health Sector Investment Project has proved this statement (consultations/population ratio and hospital utilization rates have remained quasi stationary) and demonstrated the need to initiate, early in the process, specific activities aiming a improving the demand for services. These activities are often not costly and can also be used to

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reach other objectives such as educating the consumer on health issues, inducing behavioral changes, increasing user’s involvement in health facility management. For that reason, demand raising activities and community involvement will receive HNSP funding with priority. In fact, the community-based nutrit ion communications program i s intended to include next to direct key-behavior messages to improve young chi ld feeding-practices, messages on basic health which raise awareness and create demand for services.

6. Alternatives considered and reasons for rejection

Lending instrument: As mentioned, the proposed HNSP would be a follow-on operation to the previous Health Sector Investment Project and the Nuh-icom Project and it would be financed through a Specific Investment Loan (SIL). The proposed operation would utilize a sector-wide approach similar to the one applied successfully during the implementation o f the Health Sector Investment Project but with a broader scope, as the HNSP will support not only the MOHSA policy for the health sector but also the SECF policy for nutrition. The annual program review and operational planning process (POAS) will continue to be the main instrument for monitoring, allocating resources, reaching consensus and planning. The HNSP wil l not use common implementation arrangements and pooling of funds to which most donors in Mauritania do not adhere as yet. IDA moneys for c iv i l works will be pre-identified. The remainder o f IDA funds will be allocated through the POAS process to support activities aiming at addressing five key health and nutrit ion issues as stated in section B4 on HNSP components and Annex 4 on HNSP detailed description.

Other lending instruments and approaches also considered were:

Two freestanding follow-up operations to the previous Health Sector Investment Project and Nutricom to be financed through a PRSC were init ially envisaged. This formula was rejected because o f the delay incurred in the PRSC and also in an attempt to use resources more rationally. A supplemental financing to the Health Sector Investment Project was also considered and rejected as such financing was not meeting the conditions stipulated in the Operational Policies. The choice o f a Development Policy Lending was also proposed. Such a lending instrument was not found feasible since it requires an IMF program on track (which i s currently not the case in Mauritania). In addition, a budget support instrument would not be optimal for the execution o f community based health and nutrition activities (that are central t o the proposed operation). The choice o f an APL was discussed and rejected as future financing needs for the sector are hard to predict at this point in time in Mauritania (e.g., in a few years exploitation o f o i l reserves may improve the financing o f the sector and may also impact on donor financing and programs). Classical targeted investment projects were considered as an alternative to one single sector-wide project and discussed with the Government and donors. Such projects may yield more immediate benefits and disburse IDA funds more promptly. However, the drawbacks o f the approach would outweigh advantages as it would (i) create and undue reliance o n donor-initiated decisions; (ii) delay and detract from MOHSA and SECF policies; (iii) may not be the best vehicle for sector reform; and (iv) provide narrower sector and health status benefits. The rationale for combining health and nutrition was also supported by the interrelationship between malnutrition and disease and by the need to coordinate health and nutrition activities to create synergy and avoid duplication.

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C. IMPLEMENTATION

1. Partnership arrangements

During the implementation of the Health Sector Investment Project and the Nutr icom Project, relations with donors, NGOs and other sectors improved substantially, a l l major policy documents were developed in close consultation with external and internal partners most o f whom became also active partners in program implementation. The annual operational planning process was valuable in building partnership as it provided an opportunity to comprehensibly exchange information on the situation in the sector, and on the activities being implemented or planned thus helping to reduce duplication and better focus on sectoral priorities. The role of various external partners and the content o f their programs became better understood. For instance, WHO has focused on disease control programs and pol icy matters, UNICEF on nutrition and ch i ld survival programs and policy including immunizations, UNFPA on reproductive health and supporting technically the demographic and health survey, and the population census (the latter activities were executed by ONS (OfJice National de la Statistique), the French cooperation supported among other things the set up o f the drug procurement facility and warehouse.

IDA took the lead in public expenditure analysis and capacity building and also played a leading role in donor coordination and i t s role as last resort lender was wel l appreciated. As a result o f successful donor coordination work, a Memorandum o f Understanding was signed and a “Partner Group for the Development o f Health, Social Action and Nutrit ion Sectors” was created.

The MOHSA has already demonstrated i ts interest and leadership. The M O H S A decided on a Donors Coordination leader who assisted the Government in the coordination o f donor assistance programs and activities. The partner group supported and advised the M O H S A and the SECF during the preparation o f the national health and nutrition policies, including in the deepening o f the analysis on core bottlenecks, in carrying out a detailed institutional and organizational capacity analysis at a l l levels o f the health sector, and in elaborating the MTEF.

The identification and preparation of the proposed HNSP i s the result o f intensive discussions with al l key bilateral and multilateral donors and UN technical agencies. All those partners have endorsed and welcomed this process and have pledged to focus their interventions to maximize their contribution to the achievement o f the objectives o f the health and nutrition policies and MTEF.

All the above mentioned partnership arrangements will be further strengthened, used and supported by the HNSP.

2. Institutional and implementation arrangements

Implementation will emphasize the strengthening o f national health systems and capacity. Common procedures and implementation mechanisms, according to country specific guidelines, will progressively be established and adopted in a move towards program supporthudget support as capacity improves. The project will support Annual Operational Plans (POAS) which give the M O H S A and the SECF the responsibility for choosing actions in accordance with established priorities found in their respective sectoral policies. T h i s approach provides some flexibil i ty while ensuring accountabilities towards reaching results and outcomes. Furthermore, an agreement between the M O H S A and the SECF will be signed in order to clarify and define respective roles and responsibilities with regard to the implementation o f the project, specifically, referral and outreach.

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Technical Implementation Arrangements:

MOHSA: A decree (number 025 dated M a y 5, 2005) on the attributions o f the M O H S A has recently been adopted to better respond to the requirements o f the National Health and Social Action Policy and to achieve the MDGs. To this end, a new organigramme has been elaborated and the implementation modalities for the SWAP presented in Annex 6 refer to the new organigramme.

The successful implementation o f the program will require a high level o f coordination and oversight capacity within the MOHSA. As such, and under the authority o f the Minister, the overall responsibility will lay with the Secretary General who will ensure strategic coordination o f a l l actions foreseen under the Program. The Secretary General will represent the M O H S A when liaising with cross-cutting ministries (Min is t ry o f Economic Affairs and Development and Ministry o f Civil Service) and will coordinate the overall functions and responsibilities o f the technical directorates. Technical implementation o f project activities will be fully integrated into the MOHSA structures.

SECF: The SECF will be responsible for the implementation o f the community nutrit ion activities. Whi le the central level was heavily involved in the planning and monitoring o f activities under the former Nutr icom LE project, these responsibilities will now be decentralized to the regional level. Hence, the central management unit o f the SECF will be responsible for: (i) overall coordination activities regarding the project itself and with other sectors at the central level; (ii) capacity building o f the regional level operators; (iii) technical guidance on the implementation through policy development, training and supervision; and (iv) ensuring overall financial management according to rules and procedures in close collaboration with MSASDAF.

Subsequently, the regional level will be responsible for planning and monitoring o f the activities related to the community nutrition activities and elaborating the regional-level annual action plans; and coordinating the activities within their regions. The regional services will be the decentralized structures responsible for the activities carried out at the community level. They will assist with social mobilization and ensure data collection and timely monitoring reports o f activities.

Fiduciary Implementation Arrangements Financial Management. The financial management will be handled by the DAF o f the M O H S A (for the components 4.1-4.4) and by a Finance Specialist within the SECF (for the component 4.5). The two specialists will be responsible for (a) preparing monthly Special Account (SA) reconciliation statement, and quarterly Statement o f Expenditures (SOEs) Withdrawal Schedule, quarterly financial monitoring reports, and annual financial statements; and (b) ensuring that the project financial management arrangements are acceptable to the Government and IDA. They will also be responsible for forwarding the reports and statements to the Government and IDA.

Flow of Funds. The overall project funding will consist o f IDA Credit and Counterpart Funds according to newly adopted Country Financial Parameters l imited to 90 percent. With respect to bankmg arrangements, IDA will disburse the credit through two Special Accounts (SA) operated by the M O H S A and the SECF.

Financial Reporting. All bank accounts will be reconciled with bank statements on a monthly basis. A copy of each bank reconciliation statement together with a copy o f the relevant bank statements will be reviewed monthly and will expeditiously investigate any identified differences. As the project will not be ready for report-based disbursements, it i s proposed that at the init ial stage, transaction-based disbursement procedures (i.e. direct payment, reimbursement, and special commitments), as described in the Wor ld Bank Disbursement Handbook, be followed. However, when project implementation begins

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and the borrower requests conversion to report-based disbursements, a review will be undertaken by the Bank-FMS to determine if the project i s eligible to convert to FMRs.

The project will prepare and submit to IDA Audited Project Financial Statements within six months after year end. By Credit Effectiveness, relevantly qualified external auditors will be appointed by the Government on the basis o f terms o f reference acceptable to IDA. The auditors will audit the project accounts and financial statements in accordance with International Standards o n Auditing. The audit reports will include a single opinion on (i) the Audited Project Financial Statements, (ii) the accuracy and propriety o f expenditures made under the SOE procedures and the extent to which these can be relied upon as a basis for loan disbursements, and (iii) the Special Accounts.

Medical Waste Management Arrangements: At the regional level, the DRPSS and the health districts will be responsible for the management o f medical waste within their jurisdiction; they will establish technical operating units who will oversee the implementation o f the national policies for health care facilities in their respective areas. At the level o f the health care centerhealth post, the responsible o f each o f these facilities will be in charge o f medical waste management; will be accountable for overseeing the proper application o f regulations and procedures; and will appoint teams responsible for sorting waste at the source; collection; storage; transport; and disposal o f waste. The Ministry o f Rural Development and Environment will ensure the strict application o f environmental norms and procedures (pollution standards; environmental assessment procedures and approval o f environmental studies) regarding a l l activities related to medical waste management. The Communes will be responsible for maintaining clean surroundings, and they wil l ensure that no untreated medical waste along with domestic waste i s disposed at the waste dumps which they manage. They will also be required to give their prior approval o f projects that might negatively affect public health, especially the collection, transport and disposal o f medical waste in their areas. At the level o f the health centerihealth post, the project will support the establishment o f hygiene committees and officers responsible for medical waste management at these facilities.

3. Monitoring and evaluation o f outcomedresults

As mentioned, the implementation o f the Health Sector Investment Project helped institutionalize an annual review and planning process. Consequently, during the last eight years monitoring and evaluation were regularly performed and improved. A Demographic and Health Survey (DHS) for the years 2000/2001 provided outcome data and a population census (also supported by the Health Sector Investment Project) provided reliable population data including their breakdown per regions and departments. It also helped standardize the official names for cities and villages (in Mauritania a locality could have many names and different spellings and this situation was a major hurdle for the inventory and planning for health infrastructure, and, more generally, in data reporting).

Notwithstanding these achievements, the lessons learned f rom the implementation o f the Health Sector Investment Project have also shown that (i) the Monitoring and Information system needs further improvement, (ii) more attention should be paid to data quality, (iii) the collection o f information on donor activities was incomplete and needed to be further discussed with the relevant donors, (iv) to accurately evaluate outcome and impact (health status indicators) surveys should be carried out at intervals matching the start, mid-term and end o f the operation.

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All these lessons were taken into account in the design o f the HNSP, namely: (a) adequate attention to MDGs and MDGs related indicators, (b) emphasis on and support to information and monitoring system, data quality and t imely reporting, (c) improved information on al l partners’ activities, (d) agreement on a relevant set o f monitoring indicators (including on the periodicity o f reporting) that the sector can report with a reasonable effort and cost, (e) support to surveys to take place at critical points in time in program and project development.

Additionally, the HNSP would l ikely face two factors in regard to outcome/impact evaluation. Firstly, a DHS i s costly and require a multi-donor effort both in terms o f technical assistance and money. It remains uncertain to date whether the sector will be able to carry out a DHS in 2006 and another one in 2008/2009. Secondly, the HNSP will be implemented over a short period o f time (three years) and changes in health status indicators, even if they occur, might not be measurable in a statistically significant manner (due to survey margins o f error).

Beneficiary assessments will be instrumental in collecting information on the user’s satisfaction with services and to a certain extent on behavioral aspects and there will be more collaboration with Ministry of Finance among others to improve the budget and expenditure data.

Lastly, the partners will meet once a year with the Government to review progress accomplished under the HNSP during the previous year against the agreed upon indicators and to agree on the POAS and the budget for the fol lowing year and ensure coherence with the HNSP priorities. Prior to those meetings, MOHSA will submit to donors, detailed reports on performance and planning. These meetings will also examine data quality and the needs for improving reporting and, will also examine the overall progress in the sector towards the meeting o f policy targets and MDGs.

4. Sustainability

There are major factors that will contribute to HNSP sustainability:

0 The HNSP supports the Program proposed by the Government for the health and nutrition sectors for the period 2005-2015. There i s a wide consensus and commitment to this program that i t i s built on and further develops the previous policies for the health sector (Plan Directeur 1991-1995/6, Plan Directeur 1998-2002, and Plan d’Actionpour la Nutrition -updated in 2002).

0 There i s also a demonstrated commitment by the Government towards poverty reduction and MDGs. The 2004 Public Expenditures Review: “Focusing Public Expenditure on Growth and Poverty Reduction” conducted by the Wor ld Bank has provided evidence that the Government’s pol icy has indeed been implemented, that resources have been used in accordance with i t s requirements, and that the financing o f the sector has steadily been improved.

0

development in the sector in a more down-to-earth manner. The MTEF and the anticipated enhanced collaboration with Ministry o f Finance will guide the

0 The HNSP i s not an IDA triggered initiative. The Government has demonstrated ownership and i s in lead o f a l l donor activities. Furthermore, the Government i s implementing the project with i ts own staff and rightly perceives the HNSP as part and parcel o f i t s own activities for the sector.

0 The HNSP i s expected to contribute to building a sustainable structure for the implementation o f community-based activities through i ts focus on capacity building at the regional level. In addition, by the

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end o f the project, coordination between the MOHSA and SECF, the two leading agencies in the nutrition sector, will have been institutionalized into a sustainable work arrangement.

e There i s consensus with donors and other partners that the HNSP should continue the approach launched with the opportunity o f previous operations. This consensus translates into transparent relationship and mutual support and i t i s skillfully harnessed by the Government in i ts pursuit o f sectoral objectives. F rom a financial sustainability perspective, however, the answer i s less clear since, at present, the public financing to the health and nutrition sectors remains insufficient and, overall, there i s a decline in donor financing. I t i s for these reasons that the HNSP lays emphasis on improving financing and efficiency. In a medium term perspective, the exploitation o f newly discovered o i l reserves, might impact favorably on the country’s wealth and, hopefully, make a major contribution to poverty alleviation,

5. Critical risks and possible controversial aspects

Risks

Political instability and poor economic performance may hinder MSAS/SECF in mobilizing and spending sufficient resources to implement the national health and nutrition policies and attainment o f their objectives.

Diminishing resources and technical support from external partners may further weaken program implementation and hinder Government in moving the SWAP forward. Insufficient institutional capacity might not allow adequately addressing key matters on reform agenda.

Mechanisms to protect the poor will be difficult to establish and may not effectively

Risk Rating

M

M

M

S

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Risk Mitigation Measure

Progress in CAS implementation will be monitored and evaluated and assistance adjusted to meet development benchmarks. Government allocation to the sector and public budget execution will be monitored and analyzed yearly. Civil service reform wil l be sumorted. Development and implementation o f a memorandum o f understanding will improve MSAS/Donor coordination and harmonization.

Strengthening capacity in the sector will be given appropriate attention. Capacity building will raise efficiency. MOHSA and SECF capacities in procurement, financial management will be strengthened before project effectiveness and will be regularly monitored thereafter. Donors will be mobilized for obtaining technical support in a timely manner and work will be undertaken to further harmonization among a l l partners in the sector. Human Resources Development i s a priority component o f HNSP and also a priority o f other donors . Progress in Human Resources Development will be regularly monitored. Training will be further focused on essential personnel. Incentive systems to motivate health care providers to work in remote areas will be sumorted with Drioritv. Mechanisms to protect the poorest in Mauritania will be reviewed and those with effective

x-otect the affordability o f services and drugs for the poor population.

Problems with drug procurement, supply and quality could persist.

Cultural and behavioral and other factors may prevent increasing the utilization o f services md the short implementation period may not be sufficient to see behavioral changes.

The existing mechanisms for inter-sectoral collaboration at regional level will be hindered by slow decentralization by financial resources and niay have an adverse effect on health and nutrition programs.

M

M

S

measures to protect the affordability o f drugs and services supported. HNSP will support the expansion o f such good practice. Progress in implementing measures to protect the affordability o f drugs and services will be monitored and included on the agenda o f al l POAS meetings. All donors will be mobil ized to reduce these problems. HNSP will include drug issues among i t s priorities for IDA support. IEC and other demand raising activities will be carried out early in the process o f HNSP implementation. Beneficiary assessments will take place. Health providers will be rewarded depending upon performance including their attitude towards the poor. Utilizations rates will be monitored at POAS sessions. Reporting on utilization rates will be improved and the situation analyzed by DRPSSs in each facility in their respective regions. CAS will pursue a harmonious development in al l sectors and country team discussions will be fully used. Decentralization o f financial management will be supported by the project in line with Government practice.

Summary rating: The project r isks are to a very large extent the same as the risks o f the Government program for the health and nutrition sectors Le., for such a demanding program to reach i t s goals there i s need to improve financing, raise performance in al l sectors and remain firmly committed to the reform agenda and poverty reduction. With adequate progress in c iv i l service reform, political stability and economic development, however, the HNSP risks are modest.

6. Loadcred i t conditions and covenants

Conditions for negotiations: 0

0

0

Elaboration o f a Financial and Administrative Procedures Manual, and establishment o f a Financial Management System, satisfactory to IDA; Appointment o f a qualified financial management specialist appointed within the DAF o f MOHSA. Elaboration o f procurement plan for the first year o f the project.

Conditions for credit effectiveness: 0

expenditures; 0

Ini t ial deposit o f the Counterpart Funds in the Project Account to cover the f i rst six months o f project

Recruitment o f qualified external auditors.

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Covenants: 0

0

Progress reports of the Plan o f Action to be prepared by the M O H S A on a semiannual basis. An annual review report o f the Action Plan must be submitted to IDA one month before the annual review takes place.

D. APPRAISAL SUMMARY

1. Economic and financial analyses

A project specific economic and financial analysis was not conducted for this project, as: (i) HNSP i s a follow-on project to the Health Sector Investment and the Nutr icom projects for which such analyses were conducted; (ii) the HNSP overarching goal i s to assist Government to reach MDG by means of we l l proven cost effective strategies and (iii) a Public Expenditures Review was conducted recently and provided relevant information on and analysis o f the sector policy from an economic perspective. Moreover, a Medium-Term Expenditure Framework 2005-2007 was recently developed aiming to help the sector become more results-oriented, reduce inefficiencies and, to better support the Government’s efforts to reach the MDGs.

Since 2001 the trends o f donors hnding to the health sector i s decreasing while the government spending i s increasing. Donors funding represented 55 percent o f the total health expenditures in 1999 but only 29 percent in 2002 and 27 percent in 2003. In the meantime, IDA i s becoming the major donor representing 64 percent in 2003 against 14 percent o f external financing in 1998. Donors financing i s s t i l l characterized by the difficulties to track funds and the use o f separate procedures for financial resources mobilization, accounting and reporting and procurement.

Based on available data showing trends in Government spending and assuming that financing by other donors (exclusive o f IDA) does not decrease further over the next three years, i t i s projected that IDA during the three year implementation period will contribute to finance approximately 9% of total (government and donors) spending in the sector, other donors contributing to a l itt le less (an average of 6.7%). This i s a marked reduction in donor financing compared to the last four years where donors financed in average 28% of the spending in the sector. The Government intends to conduct an economic analysis of the impact o f the decreasing external funding to the sector.

The Public Expenditures Review: Mauritania, Focusing Public Expenditure on Growth and Poverty Reduction, Public Expenditure Review, June 25, 2004 (Report No. 291 67-MAU) shows the following:

Over the last years the economic performance in Mauritania has been satisfactory. Over the period 1998- 2003, real GDP growth averaged 4.3 percent 1998-2003. Macroeconomic stability was consolidated and inflation declined from 8 percent in 1998 to an average o f 4 percent over 1999-2002. The overall balance of payment position remained favorable. The recent discovery o f relatively important o i l and gas reserves could have a major impact on the economy in the medium-term. Production i s supposed to start in 2006.

Over the period 1998-2002, the allocation o f funds to the health sector increased from 1.9 to 4.0 percent of GDP, (while expenditure on health increased from $7.7 to $13.9 per capita). However, l o w absorptive capacity and late release o f funds caused an important gap between allocated budgets and actual spending.

Mauritania has made remarkable efforts in redirecting health spending towards decentralized units. N o w more than 57 percent o f the health sector budget i s spent in decentralized units compared to 40 percent targeted. However, the poorest regions have benefited less than others and equity has not been achieved

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as intended. Richer regions tend to spend more public money per person compared with the poor regions. This phenomenon will need to be redressed in the future, with a view to improving the health status o f the poorest segments o f the population.

Although the size o f cost recovery schemes at the primary, secondary and tertiary levels i s relatively small, these arrangements have succeeded in keeping drugs accessible to the poor. However recent problems cal l for the reform o f the cost recovery system in order to improve the management of i t s proceeds and better protect the utilization o f health services by the poor.

Regarding affordability of services, a system o f exemptions exists for underprivileged people, for preventive services l ike immunizations and for curative services needed in relation to conditions such as tuberculosis, leprosy etc., which have strong public externalities. As these conditions affect more frequently the poor, the health system also promotes equity. The central drug procurement facility, CAMEC, has l imited capacity to supply drugs to al l public health facilities. Stock outages o f essential drugs and vaccines are frequent.

2. Technical

The policy for the health sector i s technically sound and the issues o f quality, access and equity are addressed systematically. The Government emphasizes poverty reduction as the main objective for the country and for i t s collaboration with the Wor ld Bank, and stresses the importance o f the health sector. As the new health policy continues the policies launched by GOM in 1991 and 1998, there i s also evidence that the sector policy i s being consistently applied, i s appropriate for the country, and has started to have an impact on the health status. This i s evidenced by the last PER carried out in 2004, which has demonstrated regular improvement in financial resources (contributed by GOM) and rational use o f resources (emphasis on primary and secondary care, right ratios between investment and recurrent expenditures, and between recurrent and recurrent non-salary expenditures, a continuous effort to decentralize service delivery and decision-making, etc.). The Program will pursue cost-effective interventions (approximately 75% o f the interventions fal l in the category o f high-cost-effective interventions). The GOM will also continue to strengthen health delivery capacity at the outreach.

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The former Nutr icom LIL project envisaged a strategy o f community-based growth monitoring and promotion. However, capacity has repeatedly been shown to be inadequate to pull this o f f successfully. In practice, the emphasis turned almost entirely on weighing children with litt le or no counseling o f the caregivers to change care practices. Given the difficulties with (scaling up) the community-based growth promotion interventions, the nutrition component o f the HNSP would focus primarily on the development and implementation of a flexible nutrition communication strategy at community level. Accordingly, the HNSP intends to strengthen the communication ski l ls o f community workers without the distraction o f periodic weighing of children. Rather than insisting on monthly weighing o f children, this new operation would support dissemination o f messages using various channels simultaneously in addition to inter- personal communication. According to capacity, the communication program would in i t s simplest form focus on one theme at the time for an extended period o f time until results are obtained before moving to the next theme. Community workers can in this way focus more on results rather than running activities as they have done in the past. Where capacity i s more enhanced, these single theme campaigns can be accompanied by additional communications, including growth monitoring in those community sites where it i s working well.

Communications for behavior change i s a cost-effective approach to improving nutrition. A cost- effectiveness study conducted on the Nutrit ion Communication and Behavior Change component in Indonesia showed that with only providing educational inputs - counseling, the nutritional status o f 40% o f children improved. Results from an impact study on the Madagascar community nutrition program shows that the use o f radio for dissemination o f nutrition and basic health messages has very positive and wide-spread impact.

3. Fiduciary

The financial management assessment (Annex 7) conclude that, provided the following conditions are met prior to credit effectiveness, the Bank’s financial management requirements will be satisfied: (i) qualified financial management specialists present within MOHSA and SECF; (ii) Counterpart Funds and Special Accounts opened and init ial deposit o f Counterpart Funds made; and (iii) qualified external auditors appointed by MOHSA.

By effectiveness, the project will not be ready for report-based disbursements. Thus, at the init ial stage, transaction-based disbursement procedures, as described in the Wor ld Bank Disbursement Handbook, will be followed i.e. direct payment, reimbursement, and special commitments. However, when project implementation begins and the borrower requests conversion to report-based disbursements, a review will be undertaken by the Bank-Financial Management Specialist to determine if the project i s eligible.

4. Social

A recently conducted Public Expenditures Review rightly states that “in terms o f equity o f health spending, on average, household expenditure on health in Mauritania represents around 5.5 percent o f total expenditure, a relatively l o w level if compared to other countries in the region. Nevertheless, i t i s interesting to notice that even though the size o f health expenditure increases with the level o f well being (as expected), i t s relative weight diminishes as income level increase. T h i s means that while amongst richest households’ health expenditure i s in the order o f 4.6 percent o f total expenditure, amongst the poorest i t accounts for nearly 9 percent o f total expenditure. It i s l ikely that the unequal weight o f health expenditure between the poor and the non-poor has a negative effect on inequality”.

Cognizant of this situation, Mauritania i s committed to poverty alleviation and reducing inequities among socio economic groups. The Government health and nutrit ion policies lay a particular emphasis on the

25

provision o f adequate and affordable services to the underserved with a specific focus on the population o f remote geographical areas, women and children and the poor. Targeting areas where malnutrition rates are high i s equal to pro-poor targeting, malnutrition and poverty are intrinsically linked. I t i s anticipated that the HNSP, that i s specifically supporting the implementation o f these policies, would have a significant contribution to their success and the attainment o f the MDGs.

The fol lowing HNSP features are most relevant from a social perspective: 0 Support to further develop health facilities in the geographical zones with l o w accessibility to public or private services. 0 HNSP set o f activities aiming at improving the affordability o f services, which includes, among others, the review of current cost recovery arrangements and the support to the expansion o f cost-recovery arrangements with proven mechanisms to maintain or improve service affordability . 0 HNSP support to a more equitable distribution of resources (financial, human resources, services, drugs and vaccines) to regions and beyond, which will also take into account poverty and accessibility criteria. 0 Use o f a broad participatory approach to fully involve stakeholder and the c iv i l society. 0 Reliance on strategies o f a clear benefit to the underserved such as preventive care and primary health care development, community based interventions in nutrition, demand raising with focus on remote under-served populations, improvement o f health and nutrition providers’ behavior in regard to women, children and the poor, and motivating them to discharge preventive services. 0 Support to human resources development policy thrusts promoting a better geographical distribution of providers and the development o f a reward and incentive system for work in poor and remote areas. 0 Systematic monitoring o f the progress made in the health and nutrition sectors activities to reduce inequities at each POAS session based, inter-alia, on data f rom two Beneficiary assessments. 0 HNSP support to behavior change communication for improved health and nutrit ion as a cornerstone o f community-based health and nutrition activities. 0 Recognition o f the important role o f women in community health and nutrition, which explains why SECF i s the executing agency o f the community nutrition activities. 0 To address potential negative social impacts due to land-acquisition, the Project will refer to the Resettlement Policy Framework (RPF) that has been prepared for this project. The RPF outlines the principles and procedures to be followed in the event that land acquisition will become necessary during project implementation.

5. Environment

Potential negative environmental and social impacts (air pollution, soil and water pollution, soil erosion or loss of vegetation) might result from the construction o f health centers and posts in rural areas, and ineffective medical waste management at these facilities. To address potential impacts on the environment and public health effectively, the project has prepared (i) an Environmental and Social Management Framework (ESMF) designed to identify, assess and mitigate potential environmental and social impacts; and (ii) a Resettlement Policy Framework (RPF) to address potential negative social impacts related to land acquisition. These frameworks were prepared because the exact locations and potential localized impacts of the newhehabilitated health care facilities were no t known prior to appraisal.

Furthermore, the project will draw on the recommendations o f the National Medical Waste Management Plan, and fund those activities that are relevant to safe medical waste management at the health centers and health posts to be financed under the proposed project. Thus, the following activities will be supported by the project: (a) the establishment o f hygiene committees and appointment o f an Officer responsible for medical waste management at the health posts and health centers; (b) provision of equipment and development o f a system that allows for proper segregation o f wastes at the health

26

facilities; (c) training o f health care personnel, sanitation workers, municipal waste dump operators, and private waste collectors; and (d) public awareness campaigns regarding the dangers o f unsafe medical waste management; the costs for these activities will be included in the project cost tables. The Project Implementation Manual will include a chapter on environmental and social management to ensure potential impacts are addressed effectively during project implementation.

6. Safeguard policies

The project has triggered OP 4.01 Environmental Assessment and OP 4.12 Involuntary Resettlement due to potential negative environmental and social impacts related to the constructiodrehabilitation o f health centers and health posts, and ineffective medical waste management. The safeguard screening category i s S2; and the environmental screening category i s B. To address potential negative impacts consistent with the requirements o f these safeguard policies, the project has prepared an ESMF and a RPF. In addition to describing the environmental and social screening process, the ESMF makes recommendations regarding capacity building needs to ensure i t s effective implementation, and consultations with potentially affected persons as part o f the screening process that will take place at the time construction and rehabilitation plans are prepared. To address issues related to medical waste management at the health centers and health posts to be constructed and/or rehabilitated, the Government draws on the National Medical Waste Management Plan and will implement relevant activities (training, segregation, public awareness campaigns). This plan, plus a summary o f the project objectives and medical waste management provisions, as wel l as the ESMF and the RPF has been disclosed in Mauritania and at the Bank’s Infoshop prior to appraisal.

Safeguard Policies Triggered by the Project Yes Environmental Assessment (OP/BP/GP 4.0 1) [XI Natural Habitats (OP/BP 4.04) [I Pest Management (OP 4.09) [I Cultural Property (OPN 1 1.03, being revised as OP 4.1 1) E l Involuntary Resettlement (OP/BP 4.12) [XI Native Peoples (OD 4.20, being revised as OP 4.10) [I Forests (OP/BP 4.36) [I Safety o f Dams (OP/BP 4.37) [I Projects in Disputed Areas (OP/BP/GP 7.60)* [I Projects on International Waterways (OP/BP/GP 7.50) [I

7. Policy Exceptions and Readiness

N o pol icy exceptions are sought. The project meets the regional criteria for readiness for implementation. The credit would assure the continuation o f a range o f activities started under the n o w closed Health Sector Investment Project and use similar implementation arrangements being a follow-up project. Only minor modifications will be necessary to existing manuals and procedures to accommodate the HNSP financing. The updates in the relevant manuals was reviewed during negotiations. A formal understanding (MOU) already exists between donors supporting the national health and nutrit ion policies. Furthermore, a MOU has been elaborated to facilitate coordination between MOHSA and SECF.

* By supporting theproposedproject, the Bank does not intend to prejudice thefinal determination of the parties’ claims on the disputed areas

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Annex 1: Country and Sector Background MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

A. Country Background

Mauritania has undergone significant socio economic changes and from a predominantly nomadic society at independence (1960) i s characterized today by a high level o f urbanization. Of the 2.7 mi l l ion inhabitants, some 1.8 mi l l ion live in urban centers, including 600.000 in the capital city Nouakchott. Over 80 percent o f the country’s land surface i s desert and only the southern areas supports rain-fed vegetation, A narrow production base and low levels o f industrialization s t i l l characterize the country’s economy. Mauritania’s export base i s heavily concentrated, with nearly al l exports consisting o f two commodities: fishing and i ron ore. These commodities are highly vulnerable to sharp swings in international prices and external demand. The recent discovery o f relatively important o i l and gas reserves could have a major impact on the economy in the medium-term. Production i s supposed to start in 2006. Attempts at diversifying the economy (agriculture, livestock, tourism) have had l imited success to date. In 2003, gross national income per capita was U S $ 430.2

Mauritania was one o f the first countries to develop a full PRSP (February 2001) through a broad participatory process. Based on the analysis o f the national household survey data (2000), i t set ambitious socio-economic goals for the 2015 horizon, focusing on four main pillars: (i) accelerating private sector- led growth; (ii) anchoring growth in the economic environment o f the poor; (iii) developing human resources and ensuring universal access to basic services; and (iv) strengthening institutional capacity and governance. Mauritania has been implementing satisfactorily the PRSP and the three Progress Reports have showed that MDGs remain high on the government agenda. However, they also pointed out that under current policies and with present financial flows, Mauritania i s highly unlikely to reach the health and nutrition related MDGs, particularly with regards to the reduction o f infant and maternal mortality, malnutrition, endemic diseases control.

Over the last five years the government has defined i t s health sector pol icy in the Plan Directeur de la Santk 1998-2002 and it i s currently in the process o f adopting an updated sector policy: National Health and Social Action Policy ( N H S A P ) (i.e., Politique Nationale de Santk et d’Action Sociale 2005-2015). The implementation o f the sector policy, embedded in the PRSP and MTEF3 processes, has been supported over the last five years by several bilateral agencies and multilateral organizations including IDA and international and local NGOs. A sector wide approach (SWAP) has been used in the health sector to: (i) address the sectoral priorities; (ii) gradually reduce the duplication o f efforts brought about by the coexistence o f various donor-driven projects; (iii) strengthen local capacity in planning and management; and (iv) assist MOHSA in setting up an effective coordination mechanism.

Over the years, financial resources from the public budget allocated to the health sector have consistently been increased and used in accordance with sector needs and priorities. As mentioned, at present, the funding for the health system remains insufficient for the delivery o f a reasonable package o f care and, there i s general agreement, that the attainment o f MDGs remains unlikely. This situation i s further aggravated by deficiencies in budget execution and resource allocation (financial, human and other) and an inefficiently use o f resources.

This means that the country i s above the IDA grants threshold o f US$ 340 a head, preventing i t to benefit from

Document IntCrimaire de Cadre de DCpenses B Moyen Terne 2005-2007. IDA grants.

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The Nutr icom project (1999-2005) was a clear s i g n o f Mauritania's growing commitment to the fight against malnutrition, which had started following the International Conference on Nutrition, which prompted the elaboration o f a National Plan o f Action for Nutrit ion in 1993. The government's commitment was reaffirmed again in the PRSP where nutrition i s highlighted as one o f f ive priorities for human resource development, and the prevalence o f malnutrition i s included as one o f the performance indicators. Finally, in 2004, the government adopted the National Nutrit ion Development Policy, which outlines national priorities for the attainment o f the nutrition MDGs. Implementation o f the commitment, however, has been limited with limited financial resources from the public budget going to nutrit ion programs.

Despite the Government's commitment and o f foreseeable economic growth (the prospect o f the exploitation o f oil reserves), external support will continue to be necessary to sustain health and other social services for some years. The decrease in donor funding to the health sector4 i s also critical and justifies IDA involvement in the financing o f the health and nutrition activities in the mid-term.

B. National Health and Social Action Policy & National Nutrition Development Policy

The overall objective of the National Health and Social Action Policy (2005-2015) i s to improve the health status and social protection o f the population (and in particular o f women, children and poor) through the provision o f more accessible and quality health and social services through support to the following strategies as outlined in the two policies and the MTEF (2005-2007):

(i) develop human resources; (ii) expand coverage and quality o f health services delivery; (iii) improve the availability o f drug and other health commodities; (iv) increase the demand for health services; (v) promote social action and create an environment conductive to health and nutrition; (vi) strengthen the institutional capacity o f the sector for an improved performance.

The objectives o f the National Nutrit ion Policy include among others the reduction o f l o w birth weight, malnutrition rates among children under five and to improve the nutritional status o f pregnant and lactating women. The following strategies are proposed to achieve the objectives: (i) improve household level food security; (ii) malnutrition reduction; (iii) nutrit ion surveillance; (iv) IEC and (v) monitoring and evaluation.

The National Nutrit ion Development Policy aims to address the nutrit ion problems o f growth faltering and stunting in early childhood, acute weight deficits or wasting in children, undernutrition in women, l ow birth weight, micronutrient malnutrition, and nutrition-related chronic diseases. The general objectives are to improve household food security, to reduce malnutrition related mortality, and promote good health, care and feeding practices. Strategic focus will be on:

(i) household food security in rural, urban and emergency settings; (ii) nutrition-relevant health services related to case-management and prevention; (iii) community-based nutrition and early childhood development; and (iv) school health and nutrition.

(i) IEC and BCC; (ii) Nutritional surveillance, monitoring and evaluation; (iii) Applied research and training;

Specific interventions in each o f these areas will be developed based on the following key strategies:

Other donor funding possibilities were explored but appear highly unlikely at present. Between 1998 and 2003, other donor funds contribution as a share in health financing declined from 55 'YO o f the total health budget to 26 %. Additionally the AfDB has decided to redirect its aid to other sectors and Germany will channel its aid through budget support.

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(iv) Food standards and control; and (v) Partnership and social mobilization.

C. The Health Delivery System

The Public sector The health public delivery system in Mauritania i s structured in three levels. Tertiary care i s dispensed only in the capital ci ty by a few hospitals. Among those are the Centre Hospitalier National, the Centre Hospitalier Cheick Zaid and the Centre Neuropsychiatrique de Nouakchott with respectively 385, 100 and 80 beds. All the tertiary hospitals provide general and specialty inpatient and outpatient services, and only a fraction o f their beds could be labeled as tertiary. The importance o f these facilities should not be write o f f as they constitute the highest referral level in the country and the patients that they cannot solve can only be treated abroad at a considerably higher cost. The secondary level i s composed o f the regional hospitals located in 10 of the 13 regional (Wilaya) capital cities (Nouakchott does not have this type of facility since the tertiary hospitals perform this function, and Inchiri and Tiris Zemmour regions are being served by the regional hospitals o f the neighbor regions). The regional hospitals have 40 to 120 beds and 35 to 80 staff and provide inpatient curative care (including surgery and obstetrics) and outpatient consultations. They are designed to minimize the referral to the tertiary hospitals o f the capital city. At the basic level o f the health delivery system are the (a) health centers, (b) health posts and (c) Unitks Sanitaires de Base (USB). The health centers (61, in 2002, comprising 12 health centers type A and 49 health centers type B) are located in the capital city o f departments (Moughatta) and are typically staffed with 1 or 2 medical doctors and 9 to 14 nurses and aid-nurses. They may also have f rom 10 to 20 beds and provide a wide array o f curative, preventive and rehabilitative services (but do not have surgical capacity). The health posts (339 in 2002) are located in villages o f 600-1500 inhabitants, are staffed with 2 to 3 nurses or aide-nurses and traditional birth attendants. The USB are services provided by community health workers and traditional birth attendants at the outreach. At this level, simple curative and preventive care as wel l as assistance for safehormal deliveries are provided fi-ee o f charge. The Direction Rkgionale de la Protection Sanitaire et Sociale (DRPSS) and the Circonscription Sanitaire de Moughatta (CSM) perform regional and departmental management functions, including the supervision and training of health personnel and o f community health workers. The health delivery system i s characterized by l o w utilization rates (about 3-4 consultations per capita and per year in health centers and 60% utilization rates in regional hospitals), lacks maintenance and drugs, and it i s poorly staffed and equipped, in particular in rural areas and in the poorer regions.

The Private sector The private sector in Mauritania consists o f an impressive network o f private pharmacies spread a l l over the country and, in big cities, by private clinics (there are 24 medical clinics; and 28 medical, 32 nursing and 34 dental smaller private practices). There i s also a hospital in the capital city. In rural settings traditional healers dispense traditional medicine remedies. The recent census o f health personnel has shown that, in the entire country, the number o f health personnel in formal private practice i s small (2.9 percent o f total health personnel and 4.2 percent o f total medical personnel) suggesting that most o f the personnel in private practice are public servants working informally in the private sector. Other ministries and agencies (such as the Ministry o f Defense, SECF, SNIM) participate in health service delivery and have budget items related to health service delivery. However, the services delivered by the private sector and by other public sectors than health are not recorded in the M O H S A statistical data. Likewise, health expenditures analyses do not take into account the money spent by other ministries and agencies to provide or pay for health services. In general, and contrary to the objectives o f the health policy, there has been litt le progress so far towards an efficient mobilization of private providers.

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D. Sector Performance and Key Issues

Health and Nutrition outcomes Mauritania i s a low human development country. Since 1990 there was an encouraging pace o f improvement but the health indicators remain poor and depict, generally, a sever situation. For instance, between 1988 and 2000, the under-5 mortality rate declined from 182 to 116 per 1,000 l ive births, infant mortality rate diminished from 1 18 to 74 per 1,000 live births, and maternal mortality decreased from 930 to an estimated 747 per 100,000 live births (Demographic and Health Survey 2000-Ol), contributing to a l i fe expectancy o f 56 years in 2002 (from 53 years in 1999). Total ferti l i ty rate also declined from 6.2 percent in the eighties to 4.6 percent in 2000 but the population growth remained high at around 2.5- 2.9%. Health status indicators in Mauritania, Sub-Saharan Africa and selected countries.

Source: ONS, 2000 and IMMS 2003

Malnutrition rates improved between 1990 and 1995 but have since deteriorated. Malnutrit ion i s a serious problem especially in the rural areas, among the poorest and the very young (0-3 years) who are the most vulnerable.

Prevalence of malnutrition in children under five since 1988 Source: WB, 1990; MOP, 1992; MOP, 1996; ONS, 2001

60

50

40

30

20

10

0 1988 1990191 1995196 2000101

I +Stunting +Wasting +Underweight I

Growth faltering mainly happens within the f i rs t two years, by the end o f which approximately four in ten children have become stunted. The prevalence o f acute malnutrition or wasting i s worrisomely high, i.e., 13%. Although the prevalence peaks at the age o f 6-12 months (16%) it remains around 10% or above in

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every age-group o f children under five years old. This i s unusual and a marker o f acute problems such as infectious diseases, poor child care, and/or food shortages.

Insufficient and inequitable access to health and nutrition services The Government has invested in health facility development and the set up o f a network o f reasonably small facilities (health centers and health posts) supported by first referral facilities (regional hospitals) and by a few tertiary facilities in the capital city o f the country. Consequently, the access to health services increased f rom less than 60% o f population having access to a health facil i ty about 15 years ago to about 77% today. However, there are s t i l l large inter-regional and inter-district variations, and overall the situation remains difficult since 23% o f the population should travel more than five kilometers to reach a health center or a health post and for 10% o f the population the nearest health facility i s at more than ten kilometers. The actual situation i s more sever than the one depicted by these accessibility indicators, as this happens in the Sahara desert where there are few roads and transportation means, and the cost o f transportation i s very high. For example, i t i s very dramatic for a woman with a complicated pregnancy to reach the f i rs t facility with obstetrics and surgical capacity (as this means to travel long distances through the desert to arrive in due time at the regional hospital) and this explains to a large extent the s t i l l very high MMR. The l o w accessibility to health services i s among the main causes o f under utilization o f facilities in rural areas and central and northern regions where the population i s scattered. Poverty i s another underlining factor and the affordability o f services ranks high on the public health agenda. The government intends to update the infrastructure development plan to reduce the existing disparities in geographical accessibility, to develop outreach community-oriented services more accessible to the poor and neglected people in remote areas, to review the cost recovery policy to better protect the affordability o f services and drugs, to involve more the formal private sector in the delivery o f basic services especially in urban cities, and to mobilize communities to take on a more active role in the delivery and use o f primary health care services, building on the achievements o f the former Nutricom project which rall ied communities around community nutrition centers to provide essential child care information and basic nutrition services. However, the number o f centers i s low, only reaching a minority of the target population. Regarding severe malnutrition the government intends to improve (community) referral and case-management o f severely malnourished children in the health system.

Inadequate Financing and Inequitable Resource Allocation From 1998 to 2002 the Government has increased the share o f the public budget for health from 1.9 to 4.0% o f the GDP and actual expenditure for health increased from about U S $ 8 to U S $ 14 per capita. The Government also stated i ts commitment to the social sectors in many official documents. Nonetheless the sector remains under-funded and unable to provide the population with a reasonable package o f essential health and nutrition services. The situation i s further aggravated by: i) the chronic l o w utilization rate o f the budget (not more than 65-70% o f the budget i s actually spend and most o f expenditure takes place in the last quarter o f the FY), ii) declining donor support and iii) flawed allocation to regions (i.e., resource allocation to regions and facilities i s not l inked to performance nor does it pay sufficient attention to the needs o f the poorest regions). There i s general consensus, that the under-funding and inefficient utilization o f resources make the achievement o f MDGs questionable. Cognizant o f this situation, the Government has updated the Medium-Term Expenditures Framework (MTEF) for the period 2005 -2007 in accordance with sector budget requirements and poverty reduction objectives. Emphasis was laid on the quality and equity of the sector spending, better budget management and harmonization o f donors’ procedures. Government i s also moving quickly towards the revision o f the cost recovery system and the implementation o f mutual funds and subsidies targeting the poor and pregnant women.

Shortages of skilled and motivated health personnel Mauritania employs in the public system 274 physicians (1 physician for about 10,000 inhabitants) out o f who hal f are specialized physicians, 60 pharmacists, 47 dentists and about 2270 health providers o f other categories (technicians, nurses, aid-nurses, midwifes, aid-midwifes). The total number o f personnel o f al l

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categories (administrative and others included) employed by the public sector i s 3818 and the total number o f health personnel of al l categories in the public and private system reaches 4257.

The shortages o f qualified and motivated health and social workers along with imbalances in the skill-mix and geographical deployment (63% of the total health providers work outside Nouakchott; however only 47% o f physicians work in Wilayas) are among the key factors undermining the access, quality and utilization o f services. There are disproportionate numbers o f health providers, notably medical doctors, working in the health administration and holding administrative positions for which they are not qualified. Similarly, health providers of al l categories are more abundant in the capital ci ty and in a few better o f f regional capitals (midwifes especially but also medical doctors), although the last Health personnel census shows some progress in this regard. There i s also lack o f specialized providers in specialties l ike surgery, obstetrics, and anesthesiology. Ineffective management, training and supervision exacerbate the lack o f responsiveness o f the system. A recently conducted health personnel census documents some positive trends in HRD, part o f which can be attributed to the implementation o f innovative measures (including incentives to the staff to relocate and work in rural areas) that the proposed project would support.

Finally, skilled nutrit ion professionals are few in the health sector. At community-level, community nutrition workers have been mobilized and trained under the earlier Nutr icom project. However, they are s t i l l few in number and more mobilization and training i s needed.

Inadequate drug quality and supply Drug shortages persist in main health facilities and the capacity o f the drug procurement and distribution system needs further strengthening. Recently a Drug procurement and storage capacity was created but it has not yet started to perform adequately. There are also notable problems with drug quality, which affect both private and public pharmacies. A recently adopted pharmaceutical policy includes the setting up o f a new registration system and the development o f sufficient capacity to enforce regulation for quality control with a v iew to reducing the circulation o f l o w quality and counterfeit drugs. MOHS i s also pursuing the improvement o f regional drug warehouses and other logistics measures to better drug management, minimize loses and improve the supply o f drugs, vaccines and consumables to health facilities.

Insufficient institutional capacity resulting in poor management of resources and services The Ministry o f Health and Social Affairs (MOHSA) in not adequately staffed to provide efficient stewardship for the implementation o f the Health Sector Development Plan. The State Secretariat for Women Affairs (SECF) idem ditto suffers from inefficient stewardship in the area o f community-based nutrition, not least because the Secretariat i s much smaller and insufficiently decentralized. Program execution continues to be slowed down by the rapid turn over o f staff holding key positions and by weaknesses in financial management, execution, procurement. Issues such as decentralization, monitoring and evaluation are among the key elements which s t i l l require detailed analysis, planning and strong leadership to bring the system up to speed and create an environment based on achieving results. Coordination between M O H S A and SECF, which share the mandate for malnutrition prevention and reduction, has been problematic over the past years.

Increased resource allocation for the priority health programs or interventions to reduce problems such as TB and Malaria or to improve reproductive health have no t translated, so far, into performance improvement and significantly better outcomes. Among the causes o f this situation are weak management, poor intersectoral collaboration (in matters such as water, sanitation, nutrition, the o f control infectious diseases and maternal and chi ld health), insufficient community participation and not enough emphasis on demand creation for preventive services. The new health sector policy seeks to decentralize more the management of priority programs, to broaden the role o f health committees towards prevention, hygiene and sanitation, to support behavior changes and improve intersectoral collaboration.

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In addition, the government intends to develop performance contracts devised as means o f rewarding managers for outputs and to enable al l stakeholders to efficiently participate in the achieving o f public health objectives. The government also recognizes the need to put more emphasis on and improve communication for behavior change at community and household levels.

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Annex 2: Major Related Projects Financed by the Bank and other Agencies MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

IDA fundinp in the Health and Nutrition Sectors

The Multi-Sectoral AIDS Project (Grant H-057-MAU for SDR 15.3 millions) became effective on January 12, 2004. I t s main objective i s to maintain the level o f HIV infection that causes AIDS below the prevalence rate o f 1 percent and reduce opportunistic infections. The latest IP rating i s marginally unsatisfactory and the DO rating satisfactory.

The Nutrition, Food Security, and Social Mobilization Project (Credit 3 187- MAU for SDR 3.6 mill ion) became effective on October 13, 1999 and closed on April 30, 2005. I t s main objective was to evaluate the effectiveness o f specific activities contained in two programs--one urban and one rural--to reduce child malnutrition in a measurable way, specifically to improve the nutritional status o f mothers and children, to promote the physical development o f children, and to increase generating activities. The latest IP and DO ratings are satisfactory and marginally unsatisfactory. OED rating was unsatisfactory.

The Health Sector Investment Project (Credit 3055-MAU for SDR 17.8 millions), became effective on October, 1998 and closed on December 3 1, 2004. The main objective o f the project was to improve the health status o f the population through the provision o f more accessible and affordable quality health services. The latest IP and DO ratings are both satisfactory. OED's rating was moderately satisfactory.

The Health and Population Project (Credit 2311-MAU for SDR 15.7 millions) became effective on June 2, 1992 and closed on August 30, 1998. The main project objectives were to: (i) improve the quality and the accessibility o f basic health and family planning services; (ii) assist the Government to articulate a national population policy and define an action plan; and (iii) enhance women's ability to participate in and contribute to the country's social and economic development. OED's rating was satisfactory.

Other Donors Present in the Health and Nutrition Sectors in Mauritania

A number o f donors and international NGOs are involved in the health sector in Mauritania. These include bilateral donors (France, Spain, Germany) and multilateral agencies (AfDB, France, Spain, UNICEF, UNFPA, WHO; and KFW). These donors cover a large range o f activities and are financing several projects and are complemented by IDA lending. Most are involved in primary health care development at the district level, and projects are generally l imited to specific geographical areas. A donor coordination mechanism has been established and has improved over time under the leadership o f the M O H S A (see table below).

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Annex 3: Results Framework and Monitoring

MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

Results Framework

The HNSP overall objective i s to strengthen the health system and i t s capacity to improve the health and nutrit ion status o f the population, notably o f women, children, and the poor, as i t w i l l support the implementation o f the Government Program for the health and nutrit ion sectors during the per iod 2006-2008. The HNSP would have the following more specific objectives: (i) improve access to basic health services in underserved areas; (ii) improve the equitable allocation o f resources to underserved areas; (iii) strengthen the health sector management to raise efficiency; (iv) enhance and expand community- based communications fo r improved nutr i t ion

1) Further develop human resources and improve their geographical distribution.

2) Ensure adequate sector financing and equitable allocation o f resources for the poor and underserved geographical areas

Outcome Indicators Infant mortality rate (total and by region) Under-5 mortality rate (total and by region) Maternal mortality rate (total and by region) Contraceptive (modern methods) prevalence rate (total and by region) EPI vaccination coverage Underweight among under fives (total and by region)

Results Indicators for Each Component

Number o f intersectoral coordination meetings for the management o f human resources for health Number o f M S A S integrated supervisions with HR directorate participation Percentage o f personnel files updated

Annual revision o f the MTEF Number o f operational health mutuelles Percentage o f health management committees trained

Use of Outcome Information To monitor, evaluate and make pol icy decisions.

[t i s anticipated that HNSP inputs would bring about important improvement in processes and outputs, but major outcome changes and impact are not expected to occur during the three years o f IDA support. The following sub-set of indicators i s being proposed to monitor the progress in HNSP implementation over the three- year period.

As outcome indicators can only be measured if a D H S i s conducted and then be compared to the previous D H S (2000), progress wil l be measured by using results indicators.

Use o f Results Moni tor ing

T o monitor progress, identify bottlenecks, make t imely adjustments to activities. T o adjust the Human Resources Development Plan. T o make decisions o n staff deployment and re-deployment. To plan training activities. To ensure adequate staffing for PHC and essential referral functions such as emergency obstetrics and surgery in Regional Hospitals. T o ensure adequate funding to the sector. T o ensure that underserved areas and facilities with high proportion o f poor pop. receive adequate funding. T o monitor progress, identify bottlenecks, make timely adjustments to activities. To make timely decisions and use resources more efficiently. T o budget programs and regions based o n performance.

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PDO

3) Improve health sector management to raise efficiency

4) Improve the accessibility to quality and affordable health services in underserved areas

5) Enhance and expand community- based communications for improved nutrition

Outcome Indicators

Rate o f production o f monthly reports Holding o f the annual review o f the health sector program

Percentage o f pregnant women to receive two doses (one in the second and one in the third trimester) o f sulfadoxine- pyrimethamine (SP) Rate o f PNC in 14 Moughatas (4 Wilayas) that practice “forfait obstktrical” Rate o f mass treatment for schistosomiasis in 4 regions

Knowledge and practices o f exclusive breastfeeding for the f i rs t six months Vitamin A coverage in post-partum women and chldren under five Knowledge and consumption o f iodized salt

Use of Outcome Information To hndraise. To identify bottlenecks and make timely adjustments to training and other capacity building activities. To reward by performance. To plan training for management and administrative staff, To monitor progress, identify bottlenecks, make timely adjustments to activities. To use the information for the review and planning process (POAS) and keep donors and other stakeholders informed. To plan and adjust the Health Infrastructure Development Plan.

To monitor progress, identify bottlenecks, make timely adjustments to activities To plan training for management and f ield staff To make t imely decisions and use resources more efficiently To use the information for the review and planning process and keep donors and other stakeholders informed

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Annex 4: Detailed Project Description MAURITANIA : HEALTH AND NUTRITION SUPPORT PROJECT

The decision to chose a sector-wide approach has implications on the project design because i t renders a l l pr iori ty activities consistent with the Government health and nutrit ion policies (for which funding i s in part or in totality needed) eligible for IDA funding. While, this principle will be observed, an attempt will also be made to focus the HNSP assistance on a few critical issues, thus (i) contributing more effectively to the attainment o f the development objectives o f the sector and the achievement o f MDGs and (ii) making it feasible to evaluate the HNSP in terms o f tangible results attributable to i t s inputs. The HNSP components described below provide support to the solving o f these critical issues. The project design includes another feature specific to sector-wide approaches, i.e., funding from the credit will be allocated annually through a transparent planning process led by Government. There i s one exception to this principle Le., c iv i l works and major goods will be pre-identified because procurement for such categories takes a longer time and HNSP total duration will not exceed 3 years. I t should also be noted that HNSP as well as the overall progress in program implementation will be monitored and reviewed annually making adjustments possible at any time, should the situation in the sector undergo changes.

1. Further develop human resources and improve their geographical distribution (US$ 2.0 million)

The Government has treated human resources development as a priority for more than a decade and progress has occurred in this problem area. While the number o f health providers o f all categories has increased, many training opportunities were offered, supervision activities intensified and increasingly included on-the-job training, improvements in other areas was modest. Among the remaining issues, there i s the geographical distribution o f providers that in spite o f recent improvements continue to be a challenge, the inadequate number o f human resources, the need to increase the quality o f services discharged in the public facilities and to motivate the providers o f all categories and, in particular, those working in remote areas. There i s also necessary to continue to strengthen human resources management in the MOHSA and devolve more o f i t s tasks to regional administration. This implies strengthening the linkage between the MOHSA and other transversal ministries (Finances and Civil Services) as well as other sectoral ministries (Higher Education). This HNSP component aims at addressing this human resources development issues that are the most pressing.

The component will support activities to: (i) Professionalize the Directorate of Human Resources at all levels through: (a) strengthening human and material capacities o f the DHR in order to fulfill i t s mandate; and (b) maintaining a human resources management system that uses a forecasting and preventive approach contributing to an improved knowledge and a better distribution o f available staff (technical and administrative), in accordance with revised staffing norms, expressed needs, and available resources.

(ii) Improve coordinating mechanisms for improved human resources management through: (a) establishing a network system for information sharing between the DHR and the DRPSS on staffing, needs, etc.; (b) strengthening the capacity to manage human resources at the level o f DRPSS; (c) strengthening DHR capacity to participate in the public administration reforms

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undertaking in the country and led by the MOHSA and by other ministries, notably, redefinition of the salary scales, external recruitment process, motivation and technical premium, etc.; (d) improving coordination between the DHWMOHSA and other ministries for a l l issues concerning human resources affecting the health sector; and (e) piloting an accountability system for health care providers co-managed with the communities (Le., issues l inked with absenteeism, behavior, with identification o f potential solutions, such as establishing a performance-based system and staff evaluation system, etc.).

(iii) Improve the management and content of pre-services and in-sewice training, and on-the-job training through: (a) improving the coordination with the training institute (ENPS, INSM), while exploring possibilities o f sub-contracting with training institutes located in the sub-region; (b) improving efficiency o f the DHR to manage training abroad against needs and record and maintain personal f i le accordingly; (c) revising curricula and training programs to reflect the national health policy orientation such as quality-assurance (approach centered on the patient), environmental management, training o f trainers; and (d) improving integrated formative supervision f rom the central to the regional level and from the regional to the decentralized level.

2. Ensure adequate sector financing and an equitable allocation of resources for the poor and for underserved geographical areas (US$1.5 million)

This component has as objectives: (i) to improve the existing process and methods for mobil izing the different sources o f sector financing and for allocating them more equitably; and (ii) to strengthen measures to ensure financial accessibility to health services, to increase utilization o f services by the poorest and most vulnerable, and to rationalize the existing cost recovery system.

(I, Mobilization and allocation of sector financial resources. To further support MOHSA's progress since 2003 in improving the annual budget preparation process, the HNSP will provide technical and financial assistance to strengthen ministry capacity to: (a) prepare the annual updates o f the medium-term expenditure framework (MTEF) for the sector; (b) establish criteria for overall repartition o f budget and allocations by level o f care, region, type o f expenditure, etc.; and (c) organize annual sectoral expenditure reviews. The project will also contribute to preparatory work on national health accounts (NHA).

(ii) Financial access of the population to health services. Given the increasing financial needs o f the sector, the stabilizing o f available resources for health, and the relatively l o w level o f budgeted health expenditures over the last three years, the HNSP will support efforts: (a) to subsidize the most essential health services for the poor and other targeted populations; (b) to organize payment o f health services for the poorest and most vulnerable populations who are unable to afford even subsidized services; and (c) to help those populations interested in and able to establish alternative financing systems (mutuelles) at community level to share risks. In addition, the HNSP will provide support for strengthening the cost recovery system, including revising the regulatory basis for charging and collecting monies and training facility-level management committees.

Subsidies for essential services. The project will finance: (a) studies to evaluate the needs and define the operational modalities for subsidizing services; and (b) monitor the inclusion of adequate subsidies by the Government (and possibly other partners as well) in the annual health budget. HNSP will also support a subsidy to services for pregnant women through the expansion o f the "forfait obstktrical" 15 health facilities in the Trarza, Nouadhibou and Guidimakha regions thus extending the system to a total of nine regions. HNSP will finance training of local teams in the management o f the system, organization o f public information and

41

sensitization campaigns, and monitoring and evaluation o f the impact o f the system on pregnant women.

Payment of health services for the poorest. Based on previous operational research to test a system of payments for indigent populations, the Ministry intends to evaluate this experience, to formulate a national strategy for care o f the poorest, and to establish official regulations for identifying and caring for this population at the different levels o f the health care system. The project will contribute to al l phases o f the process: evaluation o f the program; formulation of policies, regulations, and guidelines; and financing o f program expansion in the Nouakchott, Brakna, and Assaba regions.

Organization o f mutuelles de s a d . HNSP will support continuation o f the activities o f the nine existing "mutuelles" (of which five are in Nouakchott), created with the assistance o f a project financed by the U N F P N I L O and the establishment o f an additional fifteen "mutuelles de santk" which will be community-based in rural districts. Specifically, HNSP will finance: (a) formulation o f an overall action plan and framework for developing community-based "mutuelles"; (b) operations o f a multi-disciplinary central-level team responsible for providing assistance in the creation o f the "mutuelles" and in establishing arrangements between the "mutuelles" and the relevant health facilities (health posts, health centers, and hospitals); (c) training for ministry personnel, NGO support staff, and community management o f the "mutuelle"; and (d) an init ial source o f funding for the "mutuelles." In the last year o f the Project, an evaluation of the existing "mutuelles" will be conducted and the results incorporated into legislation and regulations for creating and managing future "mutuelles de santk."

Support for strengthening the existing cost recovery system. Prior to the signature o f the credit agreement, the Government will be asked to publish regulations to ensure: (a) more transparent accounting o f receipts at health facil i ty level; (b) greater responsibility and participation o f the management committee in deciding on expenditures (from the MOH budget, facility receipts, and other sources); and (c) more consistency across health facilities with respect to the pricing o f services and drugs. HNSP will support the installation or re-dynamization, training, and operations o f the officially established management committees; to ensure the sustainability o f the health facility, a functioning management committee would be set up before providing funds for the init ial purchase o f essential drugs (for health posts financed by the project) or for the re-supply o f essential drugs to health facilities in need. HNSP will also finance the costs o f regular supervision and control o f the cost recovery system.

3. Improve health sector management to raise efficiency (US$ 1.0 million)

This component has as objectives: (i) to promote the sector-wide approach; and (ii) to develop the management capacity o f health sector personnel at a l l levels.

(i) Development of the sector-wide approach. Initiated in 1998 with support from the HSSP, the sector-wide process has advanced, and HNSP will provide support to M O H S A in the process o f formulating a memorandum o f understanding clearly establishing the objectives, roles, and relationships o f the collaboration. A draft memorandum, l imited to external donors, was circulated in February 2005; using the Health Thematic Group, the draft will be expanded to: (a) include representatives o f a l l the partners; and (b) to identify and support those key points on which further collaboration can be accelerated (e.g., coordination o f in-service training, per diem rates, etc.).

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(ii) Strengthening of sector management capabilities. HNSP will concentrate especially on: (a) enhanced coordination o f the planning and budgeting process; (b) increased budget execution through more efficient organization o f the procurement process and improved financial management; and (c) development o f measures and modalities for monitoring and evaluating the programmatic interventions.

Coordination and planning. Support from the proposed HNSP will contribute to: (a) an evaluation of the importance of the various planning approaches and instruments, particularly in the context o f the MTEF; and (b) financial support for updating the planning over the long-term (health infrastructure, equipment, and human resources development), the medium-term (the rol l ing two/three year investment plan); and the short-term, annual action plans at both regional and central levels.

Procurement. accounting and financial management. HNSP will strengthen procurement capabilities with respect to knowledge and mastery o f IDA procedures from planning, through organizing and carrying out the various tenders, to archiving the appropriate documents. The project will improve accounting and financial management by: (a) upgrading o f the management instruments used by the previous project (the financial management software; the manual of administrative, accounting, and financial procedures; the project implementation manual, etc.); and (b) contracting of a financial management consultant to provide short-term support for the Directorate o f Administration and Finance, has been merged with the Directorate o f Investment. Since financial management will be decentralized, the project will also provide assistance to the Regional Directorates, which will identify their needs annually in their action plans. An external audit of a l l project funding will be carried out on an annual basis with the final results to be submitted to IDA no later than six months after the end o f the fiscal year. !

(iii) Monitoring and evaluation. HNSP will monitor and evaluate progress within the overall context of: (a) the poverty reduction strategy through achievement o f the MDGs pertaining to health; (b) the development o f a consolidated sectoral program with common measures and procedures for supervising, monitoring, and evaluating results; and (c) the regular submission o f project reports on physical and financial results as wel l as periodic supervision o f HNSP's key performance indicators.

Achievement o f the MDGs. Within the framework o f the recently established inter- ministerial committee, which i s responsible for monitoring progress in attaining the MDGs, HNSP will: (a) contribute to financing the Demographic and Health Survey (DHS); and (b) finance (in year 3) a beneficiary incidence survey to evaluate the impact o f project actions on access to and utilization o f health services by the poor and vulnerable populations. These studies will be carried out in a manner which will allow for comparisons with similar studies conducted in 2004.

Development o f common measures and urocedures. HNSP will focus on developing common measures and procedures for supervising, monitoring, and evaluating results by financing: (a) meetings o f the Health Thematic Group to identify common indicators for measuring sectoral progress; (b) implementation o f jo in t (MOHPartner) supervision missions in the field; and (iii) organization o f a system o f performance based contracts (lettres d 'engagement) with health services and facilities. In addition, HNSP will continue the practice o f the previous project o f contributing financial and technical support for the organization o f the semi-annual sector reviews.

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Regular reporting Given MOHSA’s significant progress over the last two years in strengthening the health management information system, HNSP will continue to finance development o f the required software improvements and practical tools as well as periodic supervision at regional level.

4. Improve the accessibility to quality and affordable health services at the outreach (US$ 3.5 million)

Dispensing accessible, affordable and quality care in Mauritania i s very diff icult due to the country’s specific geographical conditions and the scarcity and high cost o f transportation and communication means. The low population density o f rural zones and the poverty o f their populations are other equally important obstacles. The Government has strived with these issues for many years and the solution chosen implies to build health facilities o f reasonably small sizes but able to treat a high number of cases and reduce, as much as possible, referral. There was improvement in infrastructure coverage in the last years but many problems remain to be solved. Among these there i s the need to better reach the poor (in general and in remote areas in particular), to raise the quality o f services, to maintain or improve drug and service affordability, and last and very important, to significantly improve the attendance o f outpatient facilities and the utilization o f hospital beds. This component aims at making a contribution to these matters.

This component support activities to improve access to and quality o f basic health services, and to raise demand for services:

(i) Construction of approximately 13 health posts and 1 health center in areas o f l o w accessibility to public or private health services. The sites o f these facilities would be chosen based on accessibility criteria, estimated number o f population in the catchment area, possible existence o f specific health problems, etc.. The facilities will benefit from maintenance and equipping, including the provision o f equipment to ensure effective medical waste management. The Health Sector Investment Project has shown that contractors cannot execute easily works for small facilities widely dispersed in the Mauritania desert and that c iv i l works take a longer time than elsewhere to implement. For this reason bidding documents will be developed before credit effectiveness.

(ii) Activities to improve access to and quality of services by: (a) the strengthening o f outreach activities from health posts and the revival o f the community approach in order to ensure improved access to preventive child, maternal and nutrition interventions for the population in hard-to-reach areas; (b) the strengthening o f the drug purchasing and distribution structures in order to ensure availability o f drugs and vaccines.

(iii) Activities to raise the demand for health and nutrition services, with emphasis on prevention, and to induce behavioral changes conducive to health and nutritional improvements; and increase community participation in the management o f health services and to render health providers more responsive to the needs o f the underserved populations.

(iv) Strengthening of the monitoring and evaluation of the quality of the services provided through the enhancement o f the integrated formative supervision, and the revitalization o f the monitoring system o f the primary health care facilities.

(v) Strategies to be supported would aim at: (a) reduction o f ch i ld mortality primarily by the extension o f the Integrated Approach to Childhood Illness (IMCI); the HNSP will support four regions in making the implementation o f this strategy possible; (b) reduction o f maternal

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mortality by the improvement o f the availability, the quality and the utilization o f emergency obstetrical and neonatal care (SONU); the HNSP will support the gradual extension o f SONU to 10 health centers; and (c) decrease in the incidence o f schistosomiasis; activities for control o f other endemic diseases already receive adequate financing from other sources such as The Global Fund for malaria and tuberculosis, or GAVI for vaccination, as well as UNICEF, WHO and the Wor ld Bank MAP for HIV/AIDS. However, if needed, these areas would also be eligible for funding f rom the credit.

5. Enhance and expand community-based communications for improved nutrition (US$2.0 million)

Priority actions include: (i) Improve and expand community-based communications for improved nutrit ion including better access to basic essential health and nutrition services; (ii) support to the application o f the salt iodization law (in close collaboration with UNICEF) and the promotion o f iodized salt consumption; and (iii) strengthen capacity of the SECF to plan, monitor and evaluate nutrition communication program implementation. These priority actions will be implemented through community mobilization, training o f polyvalent community agents, and interpersonal communication supported by group and mass communication. The HNSP wil l focus primarily on the development and implementation o f a flexible nutrit ion communication strategy at community level. Accordingly, the HNSP intends to strengthen the communication ski l ls o f community workers. Rather than insisting on monthly weighing of children, the new project would disseminate messages using various channels simultaneously in addition to inter-personal communication. According to capacity, the communication program would in i t s simplest form focus on one theme at the t ime for an extended period o f time until results are obtained before moving to the next theme. Polyvalent community workers can in this way focus more on results rather than running activities as they have done in the past. Where capacity i s more enhanced, these single theme campaigns can be accompanied by additional communications, including growth monitoring in those community sites where it i s working well.

Basic essential health and nutrition services refer to essential services that can be provided by trained community agents, e.g., micronutrient supplementation, deworming, etc.. Messages about micronutrients would typically be included under the communications program to mobilize the community and raise awareness about the importance. On the basis o f a memorandum o f understanding, the MOH and the SECF will coordinate efforts and collaborate on community health and nutrition issues to avoid duplication and harmonize strategies. As a result, the community health strategy o f the MOH will be integrated with the community nutrition strategy o f the SECF by the creation o f community health and nutrit ion posts. Basic health and nutrition services are essential services delivered by trained community workers, for example micronutrient supplementation and deworming. Messages o n micronutrients would systematically be included in the communications program in order to mobil ize communities and sensitize them on the important role. This i s also described in the memorandum o f understanding between M O H S A and SECF which i s established in order to ensure coordination o f efforts between the two ministries, avoid duplication and harmonize strategies. In this way, in the common intervention zones, the MOHSA community health strategy would be integrated with the community nutrition strategy by creating basic health and nutrit ion posts.

A concrete example using Vitamin A as one o f the early themes would entail the following. After formative research to determine the target group and the content o f the key-messages, a training of the community volunteers would take place. A number o f different communication channels, such as radio (which has been a very successful component o f the former project), posters in the

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community, home visits by the community workers, would sensitize the community, mothers and children about the importance o f Vitamin A and would help the social mobilization around vitamin A for the distribution day. Once the monitoring data shows that all eligible children have received vitamin A and have been properly informed (supervision by regional SECF levels and health sector staff) the polyvalent community workers will be trained on the next theme, while maintaining their ski l ls and performance in vitamin A which should be distributed every six months (in close collaboration with the health sector). Other themes identified (but depending on formative research) would include exclusive breastfeeding, appropriate weaning practices, iron- supplementation during pregnancy, hand-washing and sanitation, etc) .

This also allows performance-based management to enhance capacity in a gradual manner and would provide a simplified monitoring system which, in the earlier LIL, was too complex and rated unsatisfactory.

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Annex 5: Proposed financing

MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

Financing Year

2007 2008 2009

Bank-financing YO of Bank- (US$M) financing YO o f Total Indicative Costs

(US$M) 56.00 31 1 10 61.20 33 1.5 15

65 .OO 36 2 20 ~ ~

Unallocated 5.5 55

Total Project Cost 10.00 100

182.2 Total Financing Required

IDA would support the Government’s Program for health and nutrit ion sectors acting as a last resort lender. As mentioned, HNSP could provide support to priority activities for which there i s a financial gap, provided that they are consistent with the sector pol icy and there i s agreement on their relevance. However, based on lessons learned from past operations and in particular the Health Sector Investment Project, which have showed delayed implementation in some disbursement categories, the entire set o f c iv i l works that will be supported from the credit will be pre-identified. This category combined will use less than 25 percent o f the credit and would be formalized into a Procurement and Disbursement Plan for c iv i l works. The progress in the implementation o f the procurement plan for c iv i l works will be discussed annually during the annual evaluation and planning process.

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Annex 6: Implementation Arrangements MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

T o facilitate and continue sustainable institutional development, the SWAP will be implemented using the M O H S A and the SECF structures, which will be progressively adapted to meet their mandate and functions. Measures to address capacity limitations within these ministries will be carried out prior to and during project implementation period. Training and technical assistance, including consultants/advisers will be provided, as determined, to supplement the existing capacity that i s currently inadequate to carry out expected functions. Program implementation will be monitored through periodic donors meetings organized by the MOHSA.

Implementation will emphasize the development o f national health systems and capacity. Common procedures and implementation mechanisms, according to country specific guidelines, will progressively be established and adopted in a move towards program supporthudget support as capacity improves. The project will support Annual Operational Plan (POAS), which give the M O H S A and the SECF the responsibility for choosing actions in accordance with established priorities found in their respective sectoral policy. This approach provides some flexibil i ty while ensuring accountabilities toward reaching results and outcomes. Furthermore, an agreement between the MOHSA and the SECF will be signed in order to clarify and define respective roles and responsibilities with regard to project implementation and, more specifically, the improvement and expansion o f the community nutrition activities component.

Program Technical Implementation Arrangement.

MOHSA. A decree on the attributions o f the Ministry (at a l l levels) has recently been adopted to better respond to the requirements o f the National Health and Social Action Policy (NHSAP) and to the MDGs. T o this end, a new organigramme was elaborated (see below) and the implementation modalities for the SWAP refer to the new organigramme.

The successful implementation o f the program will require a high level o f coordination and oversight capacity within the MOHSA. As such, and under the authority o f the Minister, the overall responsibility will lay with the Secretary General who will ensure strategic coordination o f al l actions foreseen under the NHSAP. The Secretary General will represent the M O H S A when liaising with cross-cutting ministries (Ministry o f Finance and Ministry o f Economic Affairs and Development, Ministry o f Civil Service, Ministry o f Higher Education etc.) and will coordinate the overall functions and responsibilities o f the technical directorates.

Technical directorates and units at the central as wel l as at the regional and district levels are responsible for implementing their activities according to agreed POAS and priorities as set in the N H S A P . As capacity will be built over the program implementation period, the POAS will be adjusted accordingly. A review o f the POAS achievements and constraints will be carried out annually and will form the basis for the preparation o f the fol lowing year’s POAS, according to priorities and potential changes in the MOHSA’s capacity to manage i ts mandate. Technical implementation o f the program will be assigned to organizational units within the ministry according to their comparative advantage. Strengthening measures to equip these units to meet these challenges will be part o f the POAS.

Central Level (a) Direction des Afaives FinanciBres (DAF). Under the overall responsibility o f the

Secretary General, the DAF will function as coordinator for IDA resources and will be

48

responsible for overall administrative and financial management. The DAF will manage the allocated budget to the MOHSA in the context o f the NHSAP and will ensure financial coordination o f the program through regular supervision and audit o f a l l administrative, financial, accounting, and procurement operations. The Accounting Unit (Sewice de la Comptabiliti) will ensure budget supervision and accounting functions o f a l l program’s administrative and financial operations and will also ensure financial and accounting support needed for the carrying out o f the POAS o f the various technical directorates. The unit will provide technical support and backstopping to the decentralized levels when carrying out their budgetary, administrative, financial, accounting functions. I t will produce financial reports (periodically and annually). The Procurement Unit (Sewice de la Passation des marchis) will manage procurement functions for goods, works, and services in collaboration with the technical directorates that wil l benefit from these inputs. Direction de la Planijication, Coopbration et Information Sanitaire (DPCIS). The DPCIS will serve as the interface between the Government and the FTPs (Financial and Technical Partners) for al l issues pertaining to the operational implementation o f the N H S A P . The DPCIS will be responsible for consolidating the planning and programming o f the Ministry’s activities and ensure adequate monitoring and evaluation. The directorate will address issues that may arise during implementation and propose related corrective measures in consultation, as may be required, with the FTPs. I t will provide the link between the fiduciary and technical directorates to ensure that resources are timely made available to the technical directorates (at al l levels). The DPCIS will report directly to the Secretary General. Technical Directorates ( D m , DES, DLM, DPL, DAS, DIMM). These directorates will be responsible for the development and technical implementation o f their respective POAS. They will also provide technical support to the decentralized levels o n an ongoing basis.

Regional Level. As part o f the process leading to the decentralization and deconcentration o f responsibilities in delivering quality services, the Regional Directorate o f Health and Social Promotion (Direction rigionale pour la promotion sanitaire et sociale, DRPSS) will ensure the financial and technical management o f the program at the regional level according to the terms o f the agreement established with the central level. I t will provide technical supervision and support for activities being carried out as part o f i t s POAS and those at the Circonscription Sanitaire de Moughata.

Circonscription Sunituire de Moughutu (CSM). Under the responsibility o f a Health Team, the C S M i s the f i rst level o f management and implementation o f the program. Service delivery and implementation at that leve l are the responsibility o f the health team, who are accountable to local authorities. Measures to strengthen the capacity o f the CSM, in terms o f human resources, and financial and material resources, will also have to be provided prior to and during the project implementation period.

SECF. The SECF will be responsible for the implementation o f the improvement and expansion of the community nutrition activities component. This will be achieved using several o f the same modalities as those put in place in the context o f the previous Nutr icom project. T o this end, the management unit o f the SECF will be responsible for: (i) planning, organizing and coordinating the activities and elaborating the annual action plan for the nutrition component; (ii) ensuring timely and adequate implementation o f the activities as stated in the agreed action plan and o f the attainment o f the objectives; (iii) establishing financing agreements between the SECF and NGOs to carry out activities, where NGOs have greater comparative advantage; (iv) ensuring financial, accounting and administrative management; and (v) ensuring monitoring and evaluation o f the

49

activities and production of progress, technical and financial reports, as and when required in close collaboration with MSASDAF. The regional services will be the decentralized structures responsible for the activities carried out at the community level. They will liaise with NGOs and community-based organizations, and ensure data collection and the monitoring o f activities.

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I

3 ln

I v

Annex 7: Financial Management and Disbursement Arrangements

MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

Control R i s k s Implementing Entity Supporting the Decentralization challenge:

A. SUMMARY OF FINANCIAL MANAGEMENT ASSESSMENT

Risk Rating Risk Mitigating Measures M As a follow-up o f former Health Sector Investment

and Nutricom Projects, HNSP wi l l maintain and capitalize on existing FM Systems by adjusting and

Implementing Entity The HNSP wil l be housed at the DAF o f the MOHSA and the SECF and wil l be in charge o f al l aspects o f financial management o f the project. The HNSP will thus benefit f rom Health Sector Investment Project and Nutricom Project experience in term o f managing IDA funds. The main recommendations below relative to the financial staff, to the information system organization, and to the audits should be implemented before the effectiveness o f the project.

Staffing HNSP will appoint a Financial Management Specialist within the DAF o f with academic and professional qualification acceptable to the Bank. Reporting to the DAF, s h e should be capable o f directing and guiding the financial management operations o f the Project including the coordination o f FM operations with decentralized autonomous hospitals. Other appropriately qualified and experienced accounting support staff will be appointed by HNSP where need be.

Risk analysis The Country Financial Accountability Assessment (CFAA) revealed that the systems for planning, budgeting, monitoring and controlling public resources in Mauritania are improving but remain at a level that they do not provide sufficient reasonable assurance that funds are used for the purpose intended. The risk o f waste, diversion and misuse o f funds was assessed as partially high. The overall project risk from a financial management perspective i s therefore considered partially high. Nevertheless, various measures to mitigate these r i s k s have been agreed. The financial management arrangements for HNSP are designed to ensure that funds are used for the purpose intended, and timely information i s produced for project management and government oversight, and facilitate compliance with IDA fiduciary requirements.

As the CFAA recommendations on financial accountability reforms have not been implemented yet, the Country Risk i s assessed as partially high.

The table in the section under identifies the key risks that project management may face in achieving i ts objectives and provides a basis for determining how management should address these risks.

Various measures to mitigate these r isks have been agreed and thus the project risk f rom a financial management perspective could be moderate provided the r i s k mitigating measures are properly addressed.

Control Risks The main control risks, ratings and mitigating measures are tabulated below. The project r i sk from a financial management perspective i s considered moderate provided the risk mitigating measures below are properly addressed.

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1. FUNDS FLOW Delays in transfer o f funds from MOF (Tresor Public) to MOHSNHNSP in respect o f Counterpart Funds.

Staffing a) Shortage o f professionally high qualified accountants at regional level;

b) No basic knowledge o f computer necessary to be used at the regional level.

Accounting Policies and Procedures Adequacy o f controls over the preparation and approval o f transactions, payments, basis o f accounting, accounting standards, cash and bank transactions, project assets, etc. Internal Audit

Non-compliance with internal audit arrangements.

External Audit Project audits will be in arrears.

Reporting and Monitoring

a)

b)

c)

Management report will not be prepared timely. Bank Reconciliation Statements will not be prepared timely. Budget monitoring: Comparison o f actual with budget will not be carried out on a regular basis.

M

M

M

M

M

M

extending them to regional levels (Manual of procedures and accounting & financial software). a) The M O F will establish clear procedure and service standards for funds transfer to MOHSA that meet the FM requirements, and monitor compliance with the procedures and service standards; and b) Follow up by the DAF.

a) Provide incentives to FM regional staff on the same basis as for medical staff;

b) Provide adequate training and capacity building activities to enable implementation according to IDA procedures during preparation and after on a continuous basis. a) Control procedures w i l l be documented in the Financial & Administrative Procedures Manual (FAPM) and regularly updated; d) Accurate basis o f accounting w i l l be used; f , Fixed Assets Register w i l l be established; and e) Contract Register w i l l be maintained. a) Internal financial controller o f the MoHSA will ensure the compliance with internal audit arrangements; and b) Regular Bank supervision missions, including SOE reviews and timely follow-up on management letter issues. a) Annual external audit will be undertaken on TORS acceptable to the Bank; b) Relevantly qualified external auditors will be appointed by HNSP; and c) Annual audit reports on the financial statements will be submitted to the Bank within six (6) months after year-end. a) Annual financial statements and quarterly FMRs will be produced; b) Financial statements will be produced in a timely manner for planning, control and decision- making purposes; c) A Financial Management Consultant w i l l be retained to advise and assist on the selection and installation o f the project’s FMS; d) The new system w i l l have the capability o f linking physical and financial data; e) Quarterly reporting arrangements, including contents o f reports, will be documented in the FAPM; f) Bank reconciliation statements wi l l be prepared on a monthly basis; and g) Reports comparing budget with actual expenditures will be prepared on a monthly basis and reviewed regularly.

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Information Systems:

Data consolidation may not work because of unexpected lack o f communication between MoHSA and SECF. Previous Project's

1 information system has not given satisfactory results in terms o f timeliness and accuracy.

a) Harmonization o f existing computerized Accounting System wil l be developed with provision for unit to be set up at regional levels (limited to autonomous hospitals); b) The new system wil l be installed at HNSP and wil l be used for maintaining accounting records and other project related information; and

M

H - High S - Substantial M - Moderate N/L - Negligible or Low

I Strength and Weaknesses

c) Appropriate training wi l l be given to staff. I

Strength: Existing FM capacities are very important but need for updating to the new context.

Weaknesses; FM decentralization to autonomous hospital at regional level and collaboration between D A F M O H S A and SECF remain very challenging because o f poor communication.

Information Systems The existing computerized FM Systems will be revised and updated accordingly. In that regard, a Financial Management Consultant will be appointed to harmonize and customize the overall systems accordingly. H e will also train financial staff on the use o f the system.

Financial Reporting and Monitoring Monthly, quarterly and annual consolidated reports will be prepared by the financial management specialist and submitted to HNSP management and IDA for the purpose o f monitoring project implementation. Monthly: (i) a Bank Reconciliation Statement, (ii) Statement of Cash position, (iii) Statement o f expenditures, and (iv) Statement o f Sources and Uses o f funds; Quarterly: (1) Financial Reports, (ii) Physical Progress Reports, (iii) Procurement Reports, (iv) SOE withdrawal schedule, and (v) Special account statement/reconciliation.

Annually: An annual project financial statement consisting o f the following: (i) a Statement o f Sources and Uses o f funds (by Credit Categoryhy Activi ty showing IDA and Counterpart Funds separately); (ii) a Statement o f Cash Position for Project Funds from a l l sources; (iii) Statements reconciling the balances on the various bank accounts (including IDA Special Account) to the bank balances shown on the Consolidated Statement o f Sources and Uses o f funds; (iv) SOE Withdrawal Schedule listing individual withdrawal applications relating to disbursements by the SOE Method, by reference number, date and amount; and (v) Notes to the Financial Statements.

Indicative formats for the reports are outlined in two Bank publications: (i) quarterly FMRs in the FMR Guidelines, and (ii) monthly and annual reports in the Financial Accounting, Reporting and Auditing Handbook (FARAH).

Accounting Policies and Procedures Project accounts will be maintained on an accrual basis, augmented with appropriate records and procedures to track commitments and to safeguard assets. Accounting records will be maintained in dual currencies (Le. Ouguiyas and SDR or USD). The Chart o f Accounts will facilitate the preparation of relevant monthly, quarterly and annual financial statements, including information on the following: . Total project expenditures; . . Total financial contribution f rom each financier;

Total expenditure on each project component'activity; and

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Analysis o f that total expenditure into c iv i l works, various categories o f goods, training, consultants and other procurement and disbursement categories.

Annual financial statements wil l be prepared in accordance with International Accounting Standards. All accounting and control procedures wil l be documented in the FAPM, a living document that will be regularly updated by the FMS.

B. AUDIT ARRANGEMENTS

The IDA Agreement wil l require the submission o f Audited Project Financial Statements for HNSP to IDA within six (6) months after year-end. Relevantly qualified external auditors will be appointed by HNSP on TORS acceptable to IDA. A single opinion on the Audited Project Financial Statements in compliance with International Standards on Auditing will be required including the accuracy and the propriety o f expenditures made under the SOE procedures and the extent to which these can be relied upon as a basis for credit disbursements. In addition to the audit reports, the external auditors will be expected to prepare a Management Letter giving observations and comments, and providing recommendations for improvements in accounting records, systems, controls and compliance with financial covenants in the IDA agreement.

C. DISBURSEMENT ARRANGEMENTS

The overall project funding will consist o f an IDA Credit as well as Government Counterpart Funding as required under the recently approved Country Financing Parameters (CFPs) for Mauritania. A 10% overall contribution i s expected from the Government under the Operation. The following accounts will be maintained by HNSP:

(i) Two (2) designated accounts in U S Dollars with respective equivalents in current account in Ouguiyas which will be managed by HNSP. Funds will be used to make payments to suppliers in the respective contract currencies; and

(ii) A Project Account in Ouguiyas opened at the Central Bank to which Counterpart Funds will be deposited.

Interest income received on the Special accounts will be deposited to the respective project accounts or any other account o f borrower.

Summary o f Funds Flow Diagram

Sources o f Funds Donors

Bank Accounts

Bank Accounts HNSP

Counter-part Funds

I SA1 & SA2 in USD

Accounts in Account in

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Method o f Disbursements

The overall financial risk for the project has been rated partially high and, by effectiveness, the Project will not be ready for report-based disbursements. Initially, the transaction-based disbursement procedure will be followed (as described in the Wor ld Bank Disbursement Handbook), i.e. direct payment, reimbursements, special commitments and replenishments o f the Advance account.

When project implementation begins, the quarterly Financial Monitoring Reports (FMRs) produced by the project will be reviewed by IDA. Where the reports are adequate and produced on a timely basis and the borrower requests conversion to report-based disbursements, a review will be undertaken by the Bank, FMS to determine if the project i s eligible for this disbursement method. The adoption o f report-based disbursements by the project will enable it to move away from the transaction-based disbursement method to quarterly disbursements to the Project’s designated account, based on FMRs. Detailed disbursement procedures will be documented in the FAPM.

Use of statements of expenditures (SOEs)

Disbursements for al l expenditures wil l be made against full documentation, except for items claimed under the Statement o f Expenditures (SOE) procedure. SOEs will be used for payments claimed under contracts for: (i) works in an amount inferior to US$500,000, (ii) goods in an amount inferior to US$250,000; (iii) consulting f i r m s in an amount inferior to US$lOO,OOO and (iv) individual consultants in an amount inferior to US$50,000, as wel l as a l l small equipment, office supplies and training. Documentation supporting a l l expenditures claimed against SOEs will be retained by HNSP or any decentralized HNSP office in Mauritania and the documentation will be made available for review by IDA periodic supervision missions and project external auditors. All disbursements are subject to the conditions o f the Financing Agreement and the procedures defined in the Disbursement Letter.

Designated Accounts

T o facilitate project implementation and reduce the volume o f withdrawal applications, two (2) Designated Accounts in U S dollars with respective equivalent in local currency current account (Ouguiyas) would be opened by HNSP in a commercial bank or at Central Bank on terms and conditions acceptable to IDA. The required characteristics for a bank acceptable to IDA has been provided to Government should MoHSA. The authorized allocations would be US$1.3 mi l l ion for Special Account A (MoHSA) and US$450,000 for Special Account B (SECF). The respective allocations will cover about six months o f eligible expenditures. HNSP will be responsible for submitting monthly replenishment applications with appropriate supporting documents for expenditures. Since country legislation does not al low local commercial banks to handle payments in foreign currency, such payments will be made by the Central Bank o f Mauritania. M O H S A will ensure with the Ministry o f Finance that foreign currency payments to suppliers o f goods and services under the HNSP are made by the Central Bank within 3 days o f submission o f an invoice. Given the short implementation period and the expected quick results o f this operation, IDA will grant a six months’ advance to MOHSA. The flexibil i ty should allow MoHSA to finance most o f IDA’S share o f expenditures through the designated accounts. The designated accounts will be replenished through the submission o f Withdrawal Applications on a monthly basis and will include a reconciliation o f the account and relevant bank statements and other documents as required until such time as the borrower may choose to convert to report-

56

based disbursement. The borrower may also choose to pre-finance project expenditure and seek reimbursement from IDA, as needed.

Upon credit effectiveness, IDA will deposit the amount o f US dollars 1.3 mi l l ion into designated account A (MoHSA) and US dollars 450,000 into designated account B (SECF). The designated accounts will be used for all payments inferior to twenty percent o f the authorized allocation and replenishment applications will be submitted monthly. Further deposits by IDA into the designated accounts wil l be made against withdrawal applications supported by appropriate documents.

Counterpart funds and taxes

Based on the newly adopted Country Financial Parameters, the cost sharing between IDA and the Government of Mauritania will be l imited to 90% (or 100% excluding taxes). While project costs include a l l taxes and contracts for goods and services are approved all-taxes included in accordance with Bank procurement rules, the borrower will be authorized to submit i t s claims for local expenditures all-taxes excluded, in order to facilitate payments, while fulfilling the CFP requirements.

Allocation of Credit Proceeds

Category

(1) Further develop human resources and improve their geographical distribution (goods, works and services) (2) Ensure adequate sector financing and an equitable allocation o f resources for the poor and for underserved geographical areas (goods, works and services) (3) Improve health sector management to raise efficiency (goods, works and services)

(4) Improve the accessibility to quality and affordable health services in underserved areas (goods, works and services) (5) Improve and expand community- based communications for improved nutrition (goods, works and services)

(6) Refunding o f Project Preparation Advance (7) Unallocated Total

Amount of the Credit Allocated (US$)

1,500,000

Percentage of Expenditures to be Financed

100% o f foreign expenditures and 100% o f local expenditures a l l taxes excluded

1,200,000 100% o f foreign expenditures and 100% o f local expenditures a l l taxes excluded

750,000 100% o f foreign expenditures and 100% o f local expenditures a l l taxes excluded

2,500,000 100% o f foreign expenditures and 100% o f local expenditures a l l taxes excluded

1,500,000 100% o f foreign expenditures and 100% o f local expenditures a l l taxes excluded

600,000

1,950,000 10,000,000

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D. NEXT STEPS

ACTION

1. Recruit a qualified financial management specialist under DAFMoHSA supervision

Update and extend FM Systems (re-customize the accounting software, adjust FAPM and train staff).

2.

Action Plan The action p lan to be implemented before negotiations i s tabulated below.

TARGET COMPLETION DATE

By negotiations

By negotiations

Conditions for negotiations The conditions for negotiations are: (i) a qualified financial management specialist appointed within the DAF o f MoHSA; (ii) update and extend at regional level the existing FM systems and train the users; and (iii) qualified external auditors appointed.

Conditions for credit effectiveness The conditions for credit effectiveness are (i) that counterpart fund arrangements are put in place and 50% o f annual forecast are released; and (ii) that the recruitment o f an external auditor i s finalized.

Financial Covenants A financial management system, including records and accounts, will be maintained by HNSP. Financial Statements will be prepared in a format acceptable to IDA, and will be adequate to reflect, in accordance with sound accounting practices, the operations, resources and expenditures in respect o f the project.

Supervision Plan Supervision activities will include: review o f quarterly FMRs; review o f annual audited financial statements and management letter as well as timely fol low up o f issues arising; and participation in project supervision missions as appropriate. The Bank F M S in charge will play a key role in monitoring the timely implementation o f the financial management arrangements.

Conclusions The overall conclusion o f the financial management assessments i s that, provided the following conditions are met by HNSP prior to negotiations, the Bank's financial management requirements will be satisfied: (i) a qualifiedfinancial management specialist appointed within the DAF of MOHSA; (ii) update and extend at regional level the existing FMsystems and train the users; (iii) Initial deposit of Counterpart Funds released; and (d) qualised external auditors appointed.

By effectiveness, the project will not be ready for report-based disbursements. Thus, at the init ial stage, transaction-based disbursement procedures, as described in the Wor ld Bank Disbursement Handbook, will be followed, i.e. direct payment, reimbursement, and special commitments. However, when project implementation begins and the borrower requests conversion to report- based disbursements, a review will be undertaken by the Bank-FMS to determine if the project i s eligible.

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Annex 8: Procurement Arrangements

MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

A. GENERAL

Procurement fo r the proposed Project will be carried out in accordance with' the Wor ld Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment o f Consultants by Wor ld Bank Borrowers" dated M a y 2004, and the provisions stipulated in the Development Financing Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Credit, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Association in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual Project implementation needs and improvements in institutional capacity.

Procurement of Works: The Project will support the construction o f health posts and one health center under the health component and o f two regional antennas for the SECF under the nu t i t i on component. Implementation o f c iv i l works will be delegated to AMEXTIPE as a delegated contract management agency. Civil works estimated to cost less than $500,000 equivalent per contract may be procured under contracts awarded on the basis o f National Competitive Bidding (NCB). N o c iv i l work contracts are envisaged above this amount, but this will occur, these contracts would be subject to International Competitive Bidding (ICB). Civil works contracts costing less than US$50,000 equivalent per contract will be procured on the basis o f simplified bidding documents (SBD) by soliciting quotations from not less than three (3) qualified domestic contractors, preferably more in order to obtain at least three comparable offers. The invitation shall include a detailed description o f the work, including basic specifications, required completion date, a basic form o f agreement acceptable to the Association, and relevant drawings, where applicable. In al l cases the award shall be made to the contractor who offers the lowest price quotation for the required work, and who has the experience and resources to complete the contract successfully. Domestic Preference will not be applicable. The procurement will be done using Bidding Documents agreed with or satisfactory to the Association.

Procurement of Goods: Goods procured under this Project are, notably, pharmaceuticals, vaccines, medical equipment and supplies, motor vehicles, motorcycles, office equipment, and furniture. Pharmaceutical products, vaccines, medical equipment and supplies may be procured through CAMEC (Centrale d'achat des medicaments essentiels et consornmables), according to procedures and bidding documents acceptable to the Association. Goods estimated to cost US$250,000 equivalent and above per contract will be procured through International Competitive Bidding (ICB). For exceptional cases (namely vaccines), and with the Association's prior approval, Limited International Bidding (LIB) may be employed. Individual contracts costing less than US$250,000 equivalent will be procured through National Competitive Bidding (NCB) procedures. Pharmaceuticals, medical equipment and supplies may be procured from UNICEF, WHO, UNFPA, and other specialized agencies o f the United Nations. Direct Contracting (DC) may be employed with prior approval o f the Association for certain cases, such as procurement of medical equipment or spare parts which must be compatible with existing equipment.

Other goods with an estimated value o f less than US$30,000 equivalent may be procured through shopping based on comparing price quotations from at least three eligible suppliers in accordance

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with IDA Procurement Guidelines (paragraph 3.5) and June 9,2000 Memorandum “Guidance on Shopping” issued by the Bank. Requests for such quotations will be in writing, and will include time and place for delivery of the quotations; a clear descriptiodspecification and quantity o f the goods; as we l l as requirements for delivery time, place for delivery o f goods, and installation requirements as appropriate. The request for quotations should be sent to at least three reputable suppliers; however, it may be preferable to approach more suppliers because no t a l l three suppliers may respond so that at least three competitive quotations are received. Quotations will be opened and evaluated at the same time. Whenever possible, goods o f similar nature, and if needed during the same period, should be grouped into packages o f US$250,000 equivalent or more, so that they can be procured through ICB to achieve the best value for money.

The procurement will be done using the Bank’s Simplified Bidding Documents (SBD) for a l l ICB and national S B D agreed with or satisfactory to the Association.

Procurement of non-consulting services: Non-consulting services will be provided using the procurement guidelines.

Selection of Consultants: Consulting services required for implementation o f the project components, including studies, technical assistance, and the supervision o f c iv i l works, which require the recruitment o f consulting f i rms or individual consultants, will be procured in accordance with the Bank’s Guidelines for the Selection and Employment of Consultants by World Bank Borrowers. All consulting services contracts (excluding assignments o f standard or routine nature, e.g. audits) above US$lOO,OOO equivalent for f i rms will be awarded o n the basis of Quality and Cost-Based Selection (QCBS) method in accordance with Part 1 o f the Guidelines. Shortlists for contracts costing less than US$lOO,OOO equivalent may consist o f national f i r m s only in accordance with provision o f paragraph 2.7 o f the Guidelines provided that a sufficient number o f qualified f i rms are available at competitive costs. However, if foreign firms have expressed interest, they will not be excluded f rom consideration. Consulting services contracts o f standard or routine nature, e.g. audits, costing less than US$lOO,OOO equivalent for f i rms will be awarded on basis o f Least-Cost Selection (LCS) method in accordance with provision o f paragraphs 3.1 and 3.6 o f the Guidelines. Consulting services contracts below the threshold o f US$lOO,OOO equivalent for f i rms may be awarded on the basis o f Consultants Qualifications (CQ) in accordance with provision o f paragraphs 3.1 and 3.7 o f the Guidelines. Individual consultants will be selected in accordance with Part V o f the Guidelines. The selection o f UN agencies and NGOs will be in accordance with paragraphs 3.15 and 3.16 o f the Guidelines. Single Source Selection may be employed with prior approval of IDA and will be in accordance with provision of paragraphs 3.9 to 3.13 o f the Guidelines.

Training Activities, including workshops and study tours, are geared toward building capacity, information sessions and improving management ski l ls. Training activities will be part o f the project’s Annual Action Plan (POAS) and will be included in annual procurement plans. The annual training program (including proposed budget, agenda, participants, location o f training, and other relevant details) will be reviewed during the Joint Review.

All works, goods, and services to be financed under the POAS will be procured in accordance with the procedures stipulated in the updated Procurement Plan.

Operating Costs: Operating costs to be financed by the project will be procured using the implementing agency’s administrative procedures reviewed and found acceptable to the Association. Operating costs include day-to-day operating expenses, such as fuel, office supplies, maintenance o f office equipment, project-related travel and supervision, salaries for local

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contractual staff, but excluding salaries o f officials o f the Borrower’s c iv i l service. Repeated procurement o f supplies and services may be procured as much as possible under annual contractual agreement.

Other: The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented in the Project Implementation Manual (PIM).

B. ASSESSMENT OF THE CAPACITY TO IMPLEMENT PROCUREMENT

Procurement activities for the health component will be carried out by the Ministry o f Health through the Directorate for Financial Affairs (DAF) at the central level. The agency i s staffed by financial management and public administration specialists, and the procurement function i s staffed by a poo l o f staff who attended training in Bank procurement areas. For activities that will be implemented by the SECF, procurement will also be carried out by the DAF o f the MoHSA.

A f i rs t capacity assessment o f the D A F M o H S A to manage procurement activities was carried out by the procurement specialist o f the Wor ld Bank country office in Nouakchott in March 2006. Capacity assessment o f CAMEC was carried out in February 2006 by the senior procurement specialist based in Washington with the field-based procurement specialist. The assessment reviewed the organizational structure for implementing the Project and the interaction between the Project’s staff responsible for procurement and the Ministry ’s relevant central unit for administration and finance.

Organization o f the Ministry of Health and Social Affairs and functions in procurement: According to the organization chart o f the MSAS approved in June 2005, the procurement function will be performed essentially by a contracts division in the DAF comprised o f experienced high level staff from the closed PASS, and equip with an adequate number o f computers, archive and filing materials. Procurement for more than 2 mi l l ion UM will be carried out by the C D M o f the MSAS, and procurement for more than 25 mi l l ion UM for goods and services and for more than 75 mil l ion UM for works will be carried out by the CCM, which has a large experience in procurement according to the procedures o f the Association.

Procurement Capacity of the Ministry o f Health and Social Affairs: MSAS has a Departmental Procurement Commission (Commission Dkpartementale des Marchis, CDM) which has a long experience in procurement according to the Association procedures. A few members o f the commission have benefited from procurement seminars financed by the Wor ld , Bank and the African Development Bank (AfDB) thanks to the projects funded by the two institutions.

Procurement Capacity of the Drug Procurement Agency, CAMEC: Pharmaceutical products, vaccines, medical equipment and supplies may be procured through CAMEC. The capacity o f this drug procurement agency to procure was assessed in February 2006, and agreed actions to strengthen i t s capacity are currently ongoing which will enable CAMEC to procure goods for the purpose o f this project and for the ongoing HIV/AIDS MAP operation.

The overall Project risk for procurement i s high.

The key corrective measures that have been agreed to are: (i) providing training to procurement specialists to strengthen the D A F M S A S and the members o f the CDM; (ii) recruiting short-term

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consultants, as needed, for specific technical activities and for capacity strengthening in procurement; (iii) establishing a contract planning and management system at the central level to be managed by administrative division o f the DAF/MSAS; and (iv) strengthening the filing and archive o f procurement-related documents, including training o f the c iv i l service in charge o f the filing. Procurement review will be carried out twice per year and an independent audit will be organized annually.

On-the-job training and in specialized institutions.

Procurement C o Weaknesses

MSAS Ongoing training

Inadequacy o f the organization o f the central procurement level.

- Establishment o f a contract managementimonitoring system - Updating o f current Manual; i t s validation and training o f personnel on utilization o f the Manual

Preparation o f a procurement plan in accordance with a model agreed upon by the Association

- Appointment and training o f a fi l ing officer. - Designing o f fi l ing system. - Procurement o f f i l ing equipment. - Training o f the internal auditor on I D A procurement procedures. - Performance o f annual financial and technical audits o f procurement

Insufficient familiarity w i th contract management - L a c k o f a computerized contract management and monitoring system. - Lacko fan acceptable manual o f procedures. Lack o f procurement planning.

Lack o f an adequate fi l ing system for procurement-related documents

MSAS - The designing o f the system and the updating o f the manual w i l l be done before effectiveness - The training w i l l take place upon effectiveness

Procurement Continuing specialist, D A F M S A S

MSAS First six months o f project implementation

MSAS First six months o f project implementation

Weakness o f internal control and audit system.

ponent Action Plan: Recommendations

- Reorganization o f central procurement departments - Deploymentirecruitment o f staff - Creation o f a pool o f specialists for DAFIMSAS Training and refresher course o f the procurement staff.

- Establishment o f a computerized contract managementimonitoring system - Adoption o f a manual (the same manual as for administrative and financial management)

Preparation o f an annual procurement plan for each department, including information on project contracts Improvement o f the current procurement filing system.

Strengthening o f internal and external control’

procurement department wi th the DAFMSAS

project

C. PROCUREMENT PLAN

The Borrower will develop a procurement plan for the f i rst year o f project implementation based on the adopted annual action plan which provides the basis for determining the procurement methods. This plan was finalized and approved by IDA during credit negotiations. As soon as the credit i s approved, the plan will be available on the project’s database and on the Bank’s external website. The Procurement Plan will be updated annually or as required to reflect the actual project implementation needs and improvement in institutional capacity.

D. FREQUENCY OF PROCUREMENT SUPERVISION

In addition to the required prior review performed by the Wor ld Bank field-office procurement specialist, two post-review missions o f procurement actions will be carried out annually.

Activity handled by the financial management component

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E. DETAILS OF PROCUREMENT ARRANGEMENTS INVOLVING INTERNATIONAL COMPETITION

1. Goods, Works, and Non-Consulting Services

(a) L i s t o f contract packages to be procured according to ICB and direct contracting procedures: pharmaceutical products, vaccines, medical equipments and supplies, vehicles, motorcycles, office equipments, etc.

(b) ICB contracts for works estimated to cost US$500,000 equivalent or more per contract, and contracts for goods estimated to cost US$250,000 equivalent or more per contract and al l direct contracting will be subject to prior review by the Bank.

2. Consulting Services

(a) The l i s t o f consulting assignments with short l i s t o f international f i r m s will be determined on a case by case basis.

(b) Consultancy services estimated to cost above US$lOO,OOO per contract for f i rms and above US$50,000 for individual consultants and al l single-source selection o f consultants ( f i rms) will be subject to prior review by the Bank.

(c) Short l i s ts composed entirely o f national consultants: Short l is ts o f consultants for services estimated to cost less than US$lOO,OOO equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines.

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Annex 9: Economic and Financial Analysis MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

1. A project specific economic and financial analysis was not conducted for this project, as: (i) HNSP i s a follow-on project to the Health Sector Investment and the Nutricom projects for which such analyses were conducted; (ii) the HNSP overarching goal i s to assist Government to reach the MDGs by means o f well proven cost effective strategies and (iii) a public expenditures review was conducted recently and provided relevant information on and analysis o f the sector policy from an economic perspective: Mauritania, Focusing Public Expenditure on Growth and Poverty Reduction, Public Expenditure Review, June 25, 2004 (Report No. 291 67-MAU). The text and tables presented below contain selected citations from this source:

A. HEALTH

2. The government health sector strategy has been oriented since the beginning o f the 1990s towards the provision o f primary health care services to the population. This resulted in the strengthening and decentralization o f the service delivery system towards the regions and the implementation o f community-based health policies. Over the last f ive years the government has defined the sector policy in the Plan Directeur de la Sante‘ 1998-2002 (PDS). The overall objective o f the strategy i s to improve the health status o f the population in general, and o f the poor in particular, through the provision o f more accessible and affordable quality health services. The program’s specific objectives are to: (i) improve health services quality and coverage; (ii) improve health’s sector financing and performance; (iii) mitigate the effects o f major public health problems; and (iv) promote social action and create an environment conducive to better health.

3. The implementation o f the sector policy over the last f ive years, embedded in the PRSP and MTEF processes, has been supported by several bilateral agencies and multilateral organizations including IDA and international and local NGOs through a sector wide approach (SWAP). The SWAP was used to address in an efficient manner the new sectoral priorities, gradually reduce the duplication o f efforts brought about by the coexistence o f various donor- driven projects, strengthen local capacity in planning and management, and assist the M O H S A in setting up an effective coordination mechanism.

4. Mauritania i s currently in the process o f shifting to programmatic lending (Press). T o this purpose the government i s preparing a new health sector pol icy and a new MTEF 2005-2007. The key challenge i s to improve the health sector implementation capacity by expanding/ enhancing the delivery system, strengthening resource management and monitoring and evaluation. The implementation o f an effective intersectoral collaboration (needed to tackle issues that the health sector cannot solve by i t s own, l i ke human resource and financial resource management) will also be critical.

Key Sector Issues 5. Health Outcomes. Health indicators in Mauritania compare favorably with neighboring countries (with the exception o f Senegal) and Sub-Saharan Afr ica as a whole. L i f e expectancy at birth i s higher than the average value for SSA and neighboring countries. Infant and under five mortality rates remain high despite the positive trends achieved in the late 1970s and OS.^ The

Taking a longer perspective, the general trends are encouraging, especially for under-5 mortality rates, which have experienced a dramatic decline from 185 per 1,000 in 1975-79 to 135 per 1,000 in 1997 and 123 per 1,000 in 2003. Child mortality, by contrast, has experienced a much slower reduction, from 95 per 1,000 in 1975-79 to 87 per 1,000 in 1997 and 74 per 1,000 in 2003. Clearly, if one

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reduction o f maternal mortality remains also a challenge. At 747 deaths per 100.000 l ive births, maternal mortality rate i s higher than the average for Sub-Saharan Africa and than in some neighboring countries, such as Senegal, Niger and Mali . Despite a l ow utilization rate o f modem contraceptives (8 percent), there has been a positive shift in fertility patterns in the last decade. The fertility index has decreased f iom 6 children per woman in 1990 to 4.7 children per woman in 2000 and to 4.6 children per woman in 2003. This i s due in part to an increase o f the median age for a woman at first birth from 18,l years in 1990-9 1 to 20.7 years in 2000 (DHS, 2000).

6. Chronic malnutrition remains a serious problem particularly in rural areas among the poor and pregnant women and the very young (0-3 year-old) that are the most vulnerable, as nearly one third of children suffer from this condition. Almost 32 percent o f children are underweight, and 10 percent are malnourished. Micronutrients disorders such as iron, folic acid, iodine and vitamin A are widespread. Infectious diseases s t i l l remain a main public health problem, in particularly malaria, and some new or reemerging diseases, such as tuberculosis, HIV infections, Schistosomiasis (see Box 1). The situation in non-communicable diseases (especially diabetes and cardiovascular diseases) i s also worsened as a result o f urbanization and improvement in living standards.

Box 1: Infectious Diseases in Mauritania

utilizes the mortality estimates presented in DHS, then the decline in child mortality and, to a lesser extent infant mortality, looks more dramatic (a new infant mortality survey using DHS methodology i s underway.

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7. Trends o f vaccination coverage have been reversed since 2000 at i t s level reached during the f i r s t ha l f o f the 1990s. The decline during the period 1995-2000 was due to the decrease o f both internal and external financing that conducted to shortages o f supplies and equipment, reduction o f personnel training, slacking o f social mobilization activities, and difficulties to carry-out outreach strategy to reach people in remote areas. Since 2000, there has been a resurgence o f the routine immunization program matched by an impressive material commitment f rom Government and external partners. As a result, DPT3 coverage has increased from 26 percent in 1999 to 82 percent in 2002. The decline o f DTP3 coverage in 2003 at 73 percent i s a clear indication that there i s n o place for complacency.

8. Primary Health Care Utilization. Health service utilization rates in Mauritania are s t i l l low, particularly for children. Due to data collection problems, it i s diff icult to provide a precise number o f visits per capita. In 2000, the HPM study found that the average number o f health visits per capita was in the order o f 0.19 vis i ts per person per year. This number was lower than 0.30 visits per capita found in 1997 in the context o f the preparation o f the Health Investment Project and through the monitoring o f health services. Recent evidence point to around 0.3/0.4 visits per person per year, more in line with the average o f such as Senegal, Benin and Guinea.

9. Access to Health Services. There i s clear evidence that the geographic accessibility to health services has improved. A comprehensive Plan de Dkveloppement des Infrastructures Sanitaires (PDIS) containing inter alia standardized building requirements and equipment lists, has served as a guide for rationalizing the distribution o f services over the last f ive years. Geographical accessibility has increased from 65 percent in 1997 to 77 percent in 2003: this means that 23 percent o f the population s t i l l must travel more than five Km to reach a health center or a health post, while 10 percent must cover more than ten Km to reach the nearest health facility. This l o w accessibility i s among the main causes for under utilization o f health services in rural areas and central and northern regions where population i s ~cat tered.~ Box 2: Public and Private Health Care in Mauritania

Public sector. inated by a public delivery system organized around three levels. At the id i s tertiary care in the capital city provided Cheick Zaid and the Centre Neuropsychiatrz Nouakchott with

. All are general and specialty hospitals staffed represent the highest referral centers in the country. Next on the pyramid are regional level secondary hospitals located in 10 o f the 13 regions (Nouakchott, Inchiri and Tiris Zemmour regions have n o regional hospitals), with 40 to 120 beds and 35 to 80 staff. These hospitals offer curative (including surgery) and preventive services. They are designed to decrease the referral volume to the center and to cut travel time for the population living in the countryside. The last level i s primary care health centers, health posts and Unit& Sanitaires de Base (USB). Health centers (61 in 2002 including 12 health centers type A and 49 health centers type B), located in department capitals, are typically staffed with 1 or 2 medical doctor(s) and 9 to 14 nurses and nurses aides and may have 10 to 20 beds. They provide a wide array o f curative, preventive, promotive and rehabilitative services. Health posts (339 in 2002) located in villages o f 600-1500 inhabitants, are staffed with 2 to 3 nurses or nurses aides and traditional birth attendants. The USB are services provided by community health workers and traditional birth attendant i s level, simple curative and preventive services as well as safeinormal deliveries are provided charge. The Direction Rkgionale de la

n Sanitaire de Moughatta (CSM) perform supervision, outreach and training o f health

ire et Sociale (DRPSg and the Circ artmental management function, in

personnel and community health workers.

’ Other factors contributing to reduce access to health services include shortages and uneven distribution o f health care providers, shortages o f drugs and equipment and the poor quality o f the bui lding which often doesn’t have complimentary infrastructure l ike water and sanitation, electricity and incinerators.

66

10. Quality of Health Care. The quality o f health care provided by public health care facilities continues to be poor leading to l o w attendance rates, low productivity and high unit costs. This i s due to:

(i) Low Incentive for Public Health Personnel. Public health personnel have weak incentives to increase their productivity in government work, since they can sell their services to private clients. In fact, the public (especially the urban non-poor) i s more l ikely to seek medical care from government-employed doctors working in private practices than f rom those working in public facilities (see Box 2 for a description o f public and private health care in Mauritania).

(ii) Misallocation of Health Personnel. Misallocation of Health Personnel. Sub-sector (technical levels) and geographical imbalances make the allocation o f health personnel inefficient. Large proportions o f health workers tend to be employed at the administration and tertiary level o f care undermining efforts to increase access to priority interventions primarily delivered through primary care services. Geographical imbalances, worsened by a centralized personnel management and a l o w human resource management capacity including the lack o f a reliable personnel management information system, limit the access to health services o f rural populations. Lower skilled staff tends to substitute for higher skilled staff in underserved areas.’ In general, the ratio populatiodpersonnel i s more favorable in the richer than poorer regions, especially for doctors.

(iii) Shortage of QualiJied StafJ: Furthermore, the sector suffers from a chronic shortage o f qualified staff, such as polyvalent nurses, public health specialists, doctors and surgeons and f rom low salaries. In the last 20 years, the real value o f the average salary in the health sectors has almost halved. The lack o f effective management and supervision in combination with low salary levels result in attitudes and practices that not only affect the technical quality o f services, but also the reputation and in turn the demand o f public services. Under these circumstances, it i s also diff icult to persuade health staff to work in rural areas, given that the attraction o f urban areas and the possibility to earn a salary in the private health sector (between 10 and 20 time higher than in the public sector) act as a powerful disincentive, notably for specialized staff.

(iv) Management of health sewice provision. The efficiency o f health care provision continues to be reduced by difficulties to integrate vertical “priority” health programs, the absence o f policy to develop collaboration with other sectors and tackle issues requiring a coordinated multi-sector action and the lack of continuity for interventions l ike vaccination,

For instance, about one third o f health personnel i s employed at the administration and tertiary level, and more than 50 percent o f doctors and 42 percent o f midwives carry out administrative duties. Similarly, more than 55 percent o f al l health workers are concentrated in Nouakchott, even though the capital city hosts “only” 35 percent o f the country’s population. In addition, o f a total o f 220 midwives, less than 50 work in the interior o f the country. And in the wilayas, a great proportion of health personnel are concentrated in regional capitals.

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prenatal care and tuberculosis control (for instance, the DTP1-DTP3 dropout rate was 16% in 2001). Whi le allocation to support services increased the availability o f vehicles and gas, supervision did not significantly improve.

11. Drug Supply. The introduction o f cost recovery at the health post and health center levels significantly improved the availability o f essential drugs, although delays affect the extension o f t h i s practice at the district hospital level. Accessibility to quality generic drugs continues to pose problems. The central warehouse (CAMEC) created in 2002 i s not yet fully functional, nor efficiently structured and managed. I t s capacity to supply drugs to al l health public facilities i s s t i l l insufficient. Stock outages o f essential drugs and vaccines are frequent recognizing amongst i t s multiple causes the absence o f an efficient and transparent procurement system and the difficulties to CAMEC to access to foreign currencies, the insufficient capacity and resources o f the regional pharmaceutical stores Dep6ts Pharrnaceutiques Rkgionaux compounded by their unspecified responsibilities. At al l levels, drug purchasing planning capacity i s deficient including in health facilities. The regulatory framework i s deficient as wel l and the capacity o f the central ministry to enforce regulation i s low, meaning that there i s some disorder in the private pharmaceutical market leading to the circulation o f l o w quality and counterfeit drugs. Financial access to drugs i s also l imited by the health practitioner’s tendency to prescribe brand name drugs instead o f their generic equivalent.

12. Sector Management and Administrative Capacity. Although the quality o f the health’s sector management has greatly improved in recent years (mainly as a result o f the SWAP and the Plan de Renforcement des Capacitks Institutionnelles (PRCI), program implementation i s s t i l l hindered by the lack o f accountability and weaknesses in national capacities for financial management, execution, procurement and audit that cause delay and disruption in program implementation. Supervision and monitoring activities aimed at improving health service quality and program implementation are not regularly carried-out at facilities level and in health districts. The system of health information i s very centralized, complex and incapable o f producing relevant and timely information for the management o f program and services, nor to provide full account of the resources used, especially at the local level. In general, the overall planning o f activities does not seem to be linked with the objectives to be attained in a coherent and effective manner.

13. Decentralization. Important progress has been made with the setting-up o f district health administration and district plans, as well as directing financial resources to the regions (these remain, however, modest). However, the mechanisms o f participation o f local communities in the management o f health services, through the Comitks de Gestion, remain weak. Local management committees are not representative o f their communities and women are absent amongst them, especially in the most disadvantaged areas. Their members are s t i l l too much focused on management o f cost recovery proceeds at the expense o f improvement o f information and prevention activities in their communities. Their participation to local planning activities i s s t i l l low. The slower pace o f the implementation o f the decentralization process contributes to delay the health sector’s progress in decentralizing the decision making to local governments at regional and district levels.

Trends in Health Expenditure (1998-2002)

14. Table 1 below presents data on the allocation and execution o f investment and recurrent spending in Mauritania for the period 1998-2002. By closely examining the table, the fol lowing generalization can be made:

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0 Allocation. Allocation of funds to the health sector increased fkom 1.9 to 4.0 percent o f GDP over the period examined. In US$ per capita terms expenditure on health increased f rom 7.7 to 13.9. Allocation of investment resources increased faster than that for recurrent spending, reaching a ration o f around 1 in 2002. Execution. Health budget execution rates substantially deteriorated over the last two years. In 2001 and 2002 execution rates were in the order o f 48 and 67 percent respectively. The gap between allocated budgets and actual spending are quite important. In 2002, for instance, actual expenditure on health amounted to 2.7 percent o f GDP or US$9 per capita, i.e. below the level o f U S 1 3 per capita, considered by the World Bank and other organizations as the minimum level of expenditure necessary to ensure a basic level o f essential services. L o w execution rates affected particularly investment expenditures, suggesting that donor contributions were not fully utilized. For instance in 2002, the execution rate o f internally financed investment expenditures reached 97 percent while the execution rate for externally financed investment expenditures was only 38.5 percent o f the allocated budget. Salary budget execution rates remained near 100 percent suggesting that the need for other operating costs was not fully met; the execution rate o f primary and secondary levels budgets was below the annual average. The budget execution rate increased from 40 percent to 68 percent in the primary sector, from 42 to 44 percent in the secondary sector, and f rom 57 percent to 70 percent in the tertiary sector. This expenditure under-run may be attributed to the low absorptive capacity o f the health sector, unable to take up a large spending on poverty reducing projects that increased sharply following the implementation o f the MTEF. The analysis suggests that the shortfall in spending may result from inaccurate estimate during the planning process and or from problems arising during execution. Three factors are contributing to the latter: (i) the general and continuing lack o f understanding about procurement procedures (IDA and government) due to an acute shortage o f trained procurement experts; (ii) cumbersome and time- consuming guidelines for procurement o f supplies and services (the CPAR recently completed identified procurement as the single most critical operational issue); and (iii) weak capacity o f the c iv i l work management agency (Amextipe) and local contractor^.^ The increase o f total health expenditures on health was due to investment expenditures until 2000. Since then the trend has been reversed and health recurrent expenditures have sharply increased in absolute terms. Their share in government total recurrent expenditures rose f rom 6.5 percent in 1998, to 7.4 percent in 2001 and 9.3 percent in 2002. On the contrary, health investment expenditures, which a share o f government investment expenditures reached 8.8 percent in 1998 and 16.0 percent in 1999, decreased to 9.7 percent in 2000 and 7.1 percent in 2002.

0

0

0

0

The decline in the execution o f health investment expenditures may have been affected largely due to insufficiency in the procurement system that caused delays in the implementation o f c i v i l works (for the construction I rehabilitation o f health posts and regional hospitals) and acquisition o f equipment.

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Table 1 : Health Expenditure Trends: 1998-2002

1998 1999 2000 2001 2002 Expenditure Allocation

Total allocation (current, OM bn) 3.606 5.170 5.240 8.670 10.639 Total allocation (constant 1998 prices, OM bn) 3.606 4.958 5.067 8.263 10.224 Total allocation (as a % o f GDP) 1.9 2.6 2.3 3.5 4.0 Total allocation (current U S $ per capita) 7.7 9.5 8.2 12.4 13.9 Recurrent Recurrent (current, allocation, OM bn.) 2.176 2.287 2.387 4.247 5.529 Recurrent (constant 1988 prices, OM bn.) 2.176 2.193 2.308 4.056 5.325 Investment Investment (current, allocation, OM bn.) 1.430 2.903 2.853 4.360 5.510 Investment (constant 1998 prices, OM bn.) 1.430 2.784 2.759 3.958 5.295 Recurrent (allocation, as a % o f total allocation 60.3 44.0 45.5 49.0 52.0 to health budget) Ratio inv.iRegu allocation 0.7 1.3 1.2 1 .o 1 .o

Expenditure Execution Total execution (current, OM bn.) 3.512 5.170 5.186 4.178 7.145 Total execution (constant 1998 prices, OM bn.) 3.512 4.958 5.015 3.982 6.866 Total execution as a % o f government total 7.6 10.2 7.6 6.4 8.5 expenditure Total execution (as a % o f GDP) 1.9 2.6 2.2 1.6 2.7

99.0 48.2 67.2 Executed health budget (as a % o f allocation) 97.4 99.6 Recurrent Recurrent (current, execution, OM bn.) 2.082 2.287 2.387 3.168 4.870 Recurrent (constant 1998 prices, O M bn.) 2.082 2.193 2.308 3.019 4.680 Recurrent (executed as a % o f allocated health 95.7 100.0 100.0 74.6 93.1 recurrent expenditure)

expenditure Investment Investment (current, execution, OM bn.) 1.430 2.884 2.800 1,010 2,275 Investment (constant 1998 prices, OM bn.) 1.430 2.766 2.708 0.963 2.186 Investment (executed as a % o f allocated health 100.0 99.3 98.1 23.1 44.5 Investment expenditure) Investment as a % o f government investment 8.8 16.0 9.7 4.4 7.1

Total execution (US $ per capita) 7.5 9.5 8.1 6.0 9.3

Recurrent as a % o f government recurrent 6.5 6.4 6.0 7.4 9.3

expenditure Recurrent (executed, as a % o f total health 59.3 44.2 46.0 75.8 68.2 executed budget) Ratio InvIRegu execution 0.7 1.3 1.2 0.3 0.5 Source: GRIM (2004a)

Functional Classification

15. Table 2 presents the breakdown o f MOHSA recurrent executed expenditures for the years 1998 to 2002. Salaries are the largest part o f health recurrent expenditures, though their share has been declining steadily - from 49 percent in 1998 to 37 percent in 2002 relative to other recurrent

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spending." Non-salary spending increased from 5 1 to 63 percent o f total recurrent expenditure over the same period.

Total recurrent executed (Urn bn) 1998 1999 2000 2001 2002 2.082 2.287 2.387 3.168 4.870

drugs -% of total recurrent)

--Maintenance --Drugs

16. Pharmaceutical products represented the second largest share o f recurrent expenditures. Their share in health recurrent expenditures increased f rom 17 percent in 1998 to 23 percent in 2000 and decreased again to 18 percent in 2002 (Table 2). Per capita expenditures for pharmaceuticals increased regularly from U S $0.5 in 1993 to 139 UM (US$ 0.73) in 1998 to 304 UM (US$1.12) in 2002. However the amount spent on pharmaceutical products under current pharmaceutical policies i s not efficient for reasons stated above. Shortages o f drugs are quite frequent in the public health system.

17 22 23 25 18 9 8 8 8 5

17. Prevention. The share o f public direct recurrent expenditures for prevention has increased to near 35 percent in average over the period 1998-2002 suggesting the emphasis put on prevention. Though there were large variations ranging f rom 30 percent in 1998 to 56 percent in 1999, 40.7 percent in 2000, 18 percent in 2001, and 30.2 percent in 2002. These figures include only materials not salaries. Table 2 below, which provides information about amounts spent on the different public health program, shows the need to increase spending for some priority health programs such as malaria, reproductive health, because o f their link with certain health outcomes (IMR, MMR, etc.).

18. Maintenance expenditures are decreasing f rom 9 percent o f recurrent expenditures in 1998 to 5 percent in 2002 despite the increase o f the total number o f equipment. Moreover, maintenance expenditures are unequally allocated among health facilities, tertiary hospitals in Nouakchott getting the bulk o f the amount allocated. In general medical equipment i s in critical situation as suggested by the high rate o f equipment outages and the Government inabil ity to replace equipment on a large scale and to put in place a long-term maintenance plan.

Economic Classification

19. Looking at a longer trend a good balance has constantly been maintained between recurrent and investment expenditures except in two periods, 1994-1995 and 1999-2000 where the ratio picked up because o f ambitious investments in facil i ty construction made under the PDS 199 1 - 1996 and PDS 1998-2002. The relative importance o f recurrent spending, amounting to 59

lo Health sector wages and salaries represented 11 percent o f the total govenunent wage bill in 1998 and 13.8 percent in 2002.

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percent o f total health allocation in 1998, decreased in 1999 and 2000 but increased sharply to nearly 76 percent in 200 1 and to nearly 68 percent in 2002.

20. This corresponds to a ratio o f allocated investment to recurrent expenditures o f 0.7 in 1998 to 1.3 in 1999, 1.2 in 2000 and about 0.5 in 2002. In 1999 and 2000, for each dollar injected into the health sector’s current expenditure, 1.3 dollars and 1.2 dollars went to investment, while the “optimal” ratio should be between 0.4 and 1. Maintaining a balance between recurrent expenditures and investment expenditure i s important to generate enough capacity o f implementing planned activities by departments. In order to ensure long-term sustainability and input balance, a basic requirement o f reviewing the recurrent cost implications o f a l l proposed investments should be enforced.

Efficiency and Equity of Health Expenditure

2 1. The health sector policy and the MTEF have been successful in improving efficiency and equity by shifting health expenditures towards: (i) high cost-effective interventions; (ii) primary health care; and (iii) services in rural and remote areas. In other words, the sector pol icy i s being oriented towards better serving the need o f the poorest segments o f the population.

22. Spending by levels of services. Although health expenditures have increased for al l levels o f services, the increase for the primary sector over the last f ive years was more marked than in other sectors. In relative terms, Table 3 shows also that the budget spent o n primary (i.e. health posts, health centers in categories A and B) and secondary (regional hospitals) care combined represented about 31 percent o f total health expenditures in 1998, 40 percent in 2000 and 51 percent in 2002, and that expenditures for tertiary care were slightly higher rising f rom 14.7 percent in 1998 to 17.6 percent in 2002. By contrast, expenditures for the administration dropped from near 54 percent in 1998 to 3 1 percent in 2002.

Table 3: Health Expenditures by Levels of Services

I exo.) I I I 29.4 I 36.5 I 31.1 I

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Source: GIRM 2004a

24. Technical Efficiency. The question

23. This trend was particularly acute with respect to wages. Figure 4.3 illustrates that salaries for primary and secondary sectors have increased sharply since 2000 since the establishment of hardship zone allowances that were given only to staff working in PHC and regional hospitals. As a result, the trend observed before 2000 i s being reverted in favor o f peripheral health facilities sector that serve urban and rural poor and that have greater externality than tertiary health care facilities.

1998 1999 2000 2001 2002 -?--Secondary ”^ _I I

+Primary Tertiary Administration

Figure 4.3 Salary Expenditures by Levels of Care 1998-2002

800 700 600 500 400 300 200 100

0

that remains i s that service delivery ’ performance has not kept up with expenditures. The hospital sub sector (see Box 2 above) accounts for 22 percent to 45 percent of public health expenditure but has also a l o w utilization rate with occupancy rates about 60 percent for tertiary hospitals and 30 percent for regional hospitals.” Reasons for this low occupancy rate could be: (i) lack of working referral mechanism from the primary to the secondary level to the tertiary level; (ii) poor quality due to shortage of adequately trained specialist physicians, shortage o f drugs and degradation o f physical infrastructure and equipment making it that regional hospitals are not very different from health centers. This prompted the government to launch a program o f rehabilitation o f seven o f nine existing regional hospitals, to create a directorate in charge o f overseeing hospital management and to design a hospital reform policy.

25. Spending by programs. T o make the most effective use o f l imited resources, the allocation for public and merit goods has been prioritized in view to ensuring the highest positive impact. Desegregation o f MOHSA expenditure on priority (vertical) health programs i s shown in Table 4. They accounted for 30.4 percent o f recurrent non-salary expenditure in 1998 and 30.2 percent in 2002 following an increase to 54 percent in 1999. Regarding the allocation o f spending to different programs, the largest actual spending was seen for immunization, then followed by reproductive health then by nutrition and HIV/AIDS. Moreover, between 1998 and 2002, the trend in the allocation of spending by programs has been uneven. Moreover, between 1998 and 2002, the trend in the allocation of spending by programs has been uneven and the increase o f spending did not significantly improve the performance o f some programs (like To and malaria programs) or interventions because of managerial problems, shortages o f personnel, insufficient decentralization to regional teams and weak coordination capacity o f the Direction de la Protection Sanitaire.

26. There has been an increase in the amount o f executed spending for reproductive health, bilharzias and nutrition as a share o f MOHSA total expenditure on health programs; a decrease for immunization; and stagnation for Nutrit ion and H IV /A IDS programs. Spending for malaria, H IV/AIDS and bilharzia/schistosomiasis control programs remains below what would have been needed. This situation i s being fixed with the new global fund for malaria, Aids and tuberculosis. GAVI i s also allocating funds in order to improve the financial sustainability o f the immunization

The number o f staff in tertiary hospitals i s disproportionately high: 496 personnel for 385 beds in the “CHN”, 306 personnel for 100 beds in “Cheik Zaid Hospital”

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program. The share o f donor-financed expenditures for a l l these programs i s high, some being financed only on external sources (schistosomiasis, reproductive health, nutrition, etc.). This indicates that despite the increased efforts by government to finance key health programs on i t s own resources, these programs remain vulnerable to decline in donor-financed expenditures.

Table 4: Ministry of Health Expenditures on Health Programs 1998-2002 (UM million)

(Source: GIRM 2004a)

Nouadhibou Nouakchott Inchiri

27. Spending by regions. Mauritania has made remarkable efforts in redirecting health spending towards decentralized units. N o w more than 57 percent o f the health sector budget i s spent in decentralized units compared to 40 percent targeted. However, the poorest regions have benefited less than others and equity has not been achieved as intended. Table 5 shows that the level of health spending in nominal terms in 2002 was twice higher in al l regions than it was in 1998, except in Hodh el Garbi where it decreased substantially. In some regions (Adrar and Tagant) health spending was 6 times higher in 2002 compared with i ts level in 1998. Table 5: Per Capita Health Expenditure by Region

2.62 3.30 3.30 1.10 1.44 1.71 1.61 17.38 13.78 23.31 3.21 6.79 7.04 3.25 3.10 3.71 7.78 8.99 4.38 7.30 0.85 1.15 1.15 2.83 7.98 17.82 12.70 28.31 22.45 37.98

74

28. The distribution o f poverty varies significantly across regions. Nouakchott, Nouadhibou and Inchir i have the lowest incidence o f poverty and Assaba, Gorgol, Guidimaka, HEG and B r a h a have the highest. An examination o f the per capita expenditure and poverty distribution shows that the reverse i s true: richer regions, i.e., those with fewer persons below the poverty line, tend to spend more public money per person compared with the poor regions. In these poorest regions (Assaba, Braha, HEG, Gorgol and Guidimaka), although per capita expenditures in nominal terms increased since 1998, their level was lower that i t was ten years ago. More effort remains to be done, to better redirect MOHSA recurrent expenditures toward the regions with the lowest incidence o f poverty. To this end, the government needs to adopt transparent mechanisms for allocating resources to the region that wil l bring more funds to the poorest ones; to introduce better budget practices and to improve fiduciary capacity both at central level and at regional level.

Impact of different sources offinance on equity

29. Private expenditure. On average, household expenditure on health in Mauritania represents around 5.5 percent o f total expenditure, a relatively l o w level if compared to other countries in the region. Nevertheless, i t i s interesting to notice that even though the size o f health expenditure increases with the level o f well-being (as expected), i t s relative weight diminishes as income level increase. This means that while amongst richest households’ health expenditure i s in the order o f 4.6 percent o f total expenditure, amongst the poorest i t accounts for nearly 9 percent o f total expenditure. It i s likely that the unequal weight o f health expenditure between the poor and the non-poor has a negative effect on inequality.

30. The greatest proportion o f health expenditure goes towards the purchase o f medicines (67 percent) followed by health vis i ts (19 percent), transport (9 percent), and hospitalization (7 percent). In general, the analysis o f the EPCV4 data shows that the poorest 40 percent o f the population have expenditure levels equal to or under the poverty line. For this people, health expenditure can contribute to further deteriorate their standard o f living towards a situation o f extreme poverty. Although in absolute terms this segment spends less that richer households, the relative high weight in health expenditure in their total expenditure means that this group i s a good candidate for benefiting from public subsidies in the future, with a v iew to facilitating i t s usage o f health care.

3 1, Cost recovery. Usually, cost recovery revenues are retainedirecycled at facilities. They are relatively small compared to expenditures incurred by the state and by donors. Cost recovery systems practiced in public health facilities for services and drugs involve tertiary hospitals, some regional hospitals and health posts and health centers which charge for a variety o f services. The better o f f population, which tends to be the primary user o f tertiary care services, pays more, as services rendered in tertiary facilities are more expensive. Conversely, the poor, who usually are the users of outreach services, pay less and s t i l l have access to affordable services o f an acceptable quality.

32. The cost recovery system has succeeded in keeping drugs accessible to the poor. For instance, despite the fact that essential drugs are sold in the public sector at about two to three times their procurement price, they are o f a better quality and seven to eight times cheaper than the drugs sold in private pharmacies. Regarding affordability o f services, a system o f exemptions exists for deprived people, for preventive services l ike immunizations and for curative services needed in relation to conditions such as tuberculosis, leprosy etc., which have strong public externalities. As these conditions affect more fi-equently the poor, the health system also promotes equity.

75

Table 6: Amount Generated by the Cost Recovery System per Year (UM million) in Public Health Facilities

Donors IDA Excl. IDA Total donors

33. Current problems with the cost recovery system are that the MOHSA has relaxed i t s control over the revenues generated since two years (with the r i sk that funds could be waist) at a time when health committees in charge o f the management o f these revenues are not functional. The co-management o f health facilities, corollary to the co financing, i s not working wel l nor the exemption system, deterring the poor and some vulnerable groups from making use o f public facilities.

1998 1999 2000 2001 2002 2003 197 370 466 623 1,091 1,342

1,209 2,452 2,236 484 983 748 1,406 2,822 2,802 1,117 2,074 2,090

34. Donors’ allocations. Table 7 below shows that the trends o f donors funding to the health sector i s decreasing while the government spending i s increasing since 2001. Donors funding represented 55 percent o f the total health expenditures in 1999 but only 29 percent in 2002 and 26 percent in 2003. In the meantime, IDA i s becoming the major donor representing only 14 of external financing in 1998 against 64 percent in 2003. Donors financing i s s t i l l characterized by the difficulties to track funds and the use o f separate procedures for financial resources mobilization, accounting and reporting and procurement.

Table 7: Health Funding by External Sources (1998-2003, UM billion)

IDA as a % o f donors financing Donors as % o f total expenditures Total donors (US$ Der caDita)

14 13 17 56 53 64 40 55 54 27 29 27 3.0 5.2 4.4 1.6 2.7 2.7

Source: GIRM 2004a

Policy Priorities

35. Based on the analysis presented, the strategy o f fight against poverty in the health sector should focus around three main axes: (i) Improve health outcomes for the poor; (ii) Secure sustainable health financing and limit the impact o f health expenditure on the revenues of poor households; and (iii) strengthen health sector management and governance.

36. I m p r o v e H e a l t h Outcomes for the poor. Scale up priori ty interventions and make them accessible to the poor. The s t i l l relatively high levels o f infant and chi ld mortality and maternal mortality underline the importance o f paying attention to preventing and curing infectious diseases, often the main cause o f mortality. Taking into account the main r i sk factors, improvement o f health indicators calls for the provision at facilities level o f an integrative package for transmittable diseases, child and maternal health and nutrition. Efforts to improve child and maternal health outcomes should go beyond the health sector and be supported through cross-sectoral interventions that include improvements in access to clean water and in mother’s education, improvements o f family food intake and change in breastfeeding practices. A new emphasis should be put on IEC and social mobilization involving other sectors, particularly local authorities and effective inter-sectoral coordination mechanisms at various levels.

76

37. Improve health care utilization by the poor and vulnerable group. Paying special attention to gender issues, behavior change, communication and social marketing can boost the demand for services. Improve Access to Health Sewice. To ensure access to the integrative package o f health services referred to above, there i s a need to pursue the development o f PHC network based upon a revised infrastructure development plan targeted on rural and underserved areas. The a i m i s to ensure, before 2010, that 90 percent o f the population has access to we l l functioning health structures (basic services) within 5 Km from the domicile. Community outreach services should be also expended.

38. Improve the Quality of Health Care:

(i) Improve the availability, management and motivation o f health personnel i s needed. Equity in the distribution o f health staff and their efficiency wil l set the pace for scaling up of interventions and pave the way for the achievement o f the MDGs. This implies improving the Human Resource Directorate; adopting the staffing norms for a l l levels o f care; better targeting deployment o f staff to critical geographical areas coupled with decentralization o f personnel administration and management to regional levels; designing a more attractive package of incentives with the full involvement o f local authorities and communities; and relying more on private providers particularly in urban areas. The quality and relevance o f the medical education also need to be improved. There i s a need to decentralize nurse schools and involve local government in their management and the selection of the students.

(ii) Increase the availability, quality and affordability o f essential drugs and consumables. The Government i s updating i t s pharmaceutical pol icy and will set up drug registration mechanisms and a quality control system. The CAMEC and regional pharmaceutical stores (DPR) will be restructures.

(iii) Improve the Management o f health service provision. The referral system should be made operational between PHC facilities and hospitals. T o consolidate the results achieved so far it i s necessary to: adopting the hospital reform policy; improve the management o f 'hospitals; win the loyalty o f specialized staff moved to regional hospitals (surgeons, obstetricians, specialized nurses, etc.); establish quality monitoring activities; and improve maintenance o f equipment. All hospitals, especially at tertiary level, should draft a medium to long-term improvement plan for both their management and quality o f care provided to users. The Government should also develop with health facilities managers performance- based contracts devised as a means o f holding them to outputs and to apply rewards and sanctions. Measures should be taken aiming at increasing involvement o f the users o f services in the management o f health facilities. Supervision activities must be intensified.

(iv) Promote maintenance activities. There i s a need to design a long-term maintenance strategy. A feasibility study should be carried-out by 2005 to establish agency. All health facilities should be provided with funds for maintenance. Procurement documents should be improved allowing for standardization o f equipment, for after-sales services and training o f users.

39. Secure Sustainable Financing and Limit the Impact o f Health Expenditures on the Revenues of the Poor. Maintain a balance recurrent and investment expenditures. In order to ensure long-term sustainability, reviewing the recurrent cost implications o f a l l proposed investments should be enforced. Redirect health spending towards under served areas. More

77

effort remains to be done, to better redirect MOHSA recurrent expenditures toward the regions with the highest incidence o f poverty.

40. Speed up ongoing reforms of the cost recovery system and promote risk-sharing mechanisms. The process should be speeded up ensuring that some medications and consumable supplies will be free o f charge (tuberculosis drugs, vaccines, vitamin A, etc.), or delivered at a reduced price (impregnated mosquito nets; services for children under five and pregnant women). A harmonized tari f f system for drugs and cost recovery for health services should be applied and a special fund should be established (from government and local communities budgets and from cost recovery proceeds) for covering the costs o f specific health services and/or o f indigents. Additionally, p i lo t experiments being conducted in Nouakchott (obstetric flat fee) and in the two Hodhs (indigence project) to convert cost recovery for services into pre-payment arrangements, should be scaled up in order to reduce the impact o f health expenditure on the poorest. The tracking o f cost recovery funds should be made regularly available.

41. Setting up a Financing Strategy. The government should design a financing strategy responding to the following characteristics: global, realistic, rigorous and flexible. There i s also a need to assess the contributions o f all stakeholders in the financing o f the health sector and to systematize the elaboration o f PER, benefit incidence studies and public expenditures tracking surveys. The institutional framework o f the financing strategy should be strengthened and the Direction des Affaires Sociales should be entitled to fol low up on a l l health financing issues including cost recovery now embedded in the Direction de la Protection Sanitaire: Improving budget management procedures and capacity.

42. Strengthen Sector Management and Governance. Strengthen sector management and administrative capacity. An assessment o f the organizational structure o f the M O H S A i s underway. I t s results will serve to restructure the ministry and i t s decentralized units. The M O H S A should improve accountability among i t s staff and managers by extending to a l l levels result-based management system to promote a culture o f result and increase efficiency and equity in the sector spending. The financial management system should be strengthened at central level and in DRPSS, C S M and hospitals. Capacity for data collection, analysis and dissemination should continue to improve by strengthening the information system.

43. Increase decentralization. The decentralization process i s just starting. Strengthening o f capacity in the Directions rkgionales and in the Circonscription sanitaires des moughatas must be considered as prerequisite for the successful implementation o f sector reforms especially the implementation of the result-based management. The links between the central level and the decentralized levels should be clarified in order to avoid duplication o f responsibilities. The government should speed up the reorientation o f community participation in order to increase the participation o f local communities in the management o f health services and protect the access o f the poor by adopting regulation that defines mandate and composition o f community health committees.

44. Modernize the Regulation of the Private Sector. Given the deep involvement o f public health workers in private practices, the l o w quality o f the services provided by the private sector and i t s outdated regulation, and the volume o f private health spending, regulation and enforcement o f quality and standards have become essential to ensure the effectiveness o f private spending. Contracts to regulate the collaboration between the public and the not-for-profit private sector have to be developed.

78

Annex 10: Safeguard Policy Issues MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

OP 4.01 Environmental Assessment

OP 4.01 was triggered due to: (i) the construction and rehabilitation o f health centers and health posts to be funded under the project; and (ii) medical waste generated at these facilities. T o address the potential negative environmental and social impacts, the project: (a) i s in the process o f preparing an Environmental and Social Management Framework (ESMF) because the precise locations o f the health posts and health centers, and the potential localized impacts could not be identified prior to appraisal; and (b) will finance: (i) equipment; (ii) training; and (iii) public awareness campaigns based on recommendations made in the National Medical Waste Management Plan.

ESMF: The ESMF will be applied by qualified personnel at the time when plans for the construction andor rehabilitation o f health posts and health centers are made to ensure that potential environmental and social impacts are identified, assessed and mitigated appropriately. Thus, the ESMF (i) describes steps 1-7 o f the environmental and social screening process; (ii) includes an environmental checklist to be appliedamended by qualified personnel as appropriate; (iii) provides generic draft terms o f reference for an environmental analysis, should one be required; and (iv) it summarizes the Bank’s operational policies to ensure that these are taken into account during project implementation as required. The ESMF furthermore includes provisions, including costs estimates, for environmental management capacity building to ensure effective implementation o f the ESMF; these costs will be incorporated into the project cost tables.

Medical waste management: To address potential negative environmental and social impacts that might result f rom unsafe medical waste management, the project will finance (i) equipment (containers for syringes, trash bins, boots, gloves, masques for the maintenance personnel; on-site sanitary pits); (ii) training for three health care personnel per health posthealth center plus weekly information sessions over a six-month period; and (iii) public awareness campaigns (production and dissemination o f television and radio messages; posters at health centers and health posts; and animation). These provisions are consistent with the National Medical Waste Management Plan, dated March 2003, that was prepared for the HIV/AIDS Project. This plan was redisclosed prior to appraisal, along with a summary o f the objectives and provisions made under the proposed project.

OP 4.12 Involuntary Resettlement

OP 4.12 was triggered due to the potential need for land acquisition which might lead to the loss o f assets, loss o f shelter, loss o f access to economic assets or loss o f livelihoods, requiring that affected persons be compensated andor resettled. T o address potential negative social impacts due to land acquisition, the project has prepared a Resettlement Policy Framework (RPF) which was disclosed in Mauritania and at the Bank’s Infoshop prior to appraisal.

The ESMF, RPF and the Medical Waste Management Plan for the Project will be disclosed in- country and at the Infoshop prior to appraisal.

79

Annex 11: Project Preparation and Supervision MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

Planned Actual PCN rev iew 03/03/2005 03/03/2005 In i t ia l PID to PIC 0313 112005 04/20/2005 In i t ia l ISDS to PIC 03/14/2005 03/14/2005 Appraisal 07/25/2005 03/06/2006 Negotiations 0 8/ 1 512005 0411 812006 B o a r d R V P approval 05/30/2006 05/30/2006 Planned date o f effectiveness 0913 0/2006 Planned date o f mid-term review 05/01/2008 Planned closing date 1213 1/2009

K e y institutions responsible for preparation of the Project: M in is t ry o f Heal th and Social Affairs State Secretariat for the Promotion o f Women

B a n k staf f and consultants who worked on the Project included: Name Title Unit

Sr. Operations Officer / Task Team Leader AFTH2 Astr id Helgeland-Lawson Cheikh Traore Cher i f D ia l lo Claudia Rokx Edeltraut Gilgan-Hunt Fat ima Cher i f HClbne Bertaud Johanne Angers Menno Mulder-Sibanda Moustapha Ould El Bechir Nestor Coffi Nico le Hamon Ousmane Bangoura Peter Bachrach RenCe M. Desclaux Sergiu Luculescu Tonia Marek Yvette Laure Djachechi

Sr. Procurement Specialist Sr. Implementation Specialist Sr. Nutrition Specialist Environmental Specialist Team Assistant Sr. Counsel Operations Off icer Sr. Nutrition Specialist Procurement Specialist Financial Management Specialist Language Program Assistant Coordinator Onchocerciasis Program Planning and Management Consultant Finance Off icer Public Heal th Consultant Lead Public Heal th Specialist Sr. Social Development Specialist

Bank funds expended to date o n project preparation: 1. Bank resources: $190,000 2. Trust funds: 3. Total: $190,000

AFTPC AFTH2 AFTH2 AFTS2

AFMMR LEGAF AFTH2 AFTH2 AFTPC AFTFM AFTH2 AFTH2

LOAG2

AFTH2 AFTS3

-

Estimated Approval and Supervision costs:

2. Estimated annual supervision cost. $120,000 1. Remaining costs to approval: $10,000

80

Annex 12: Documents in the Project F i le MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

A. Project Implementation Plan

B. Bank Staff Assessments

Public Expenditure Review, Washington DC, GIRM and World Bank, World Bank 2004e

Mauritania - Country Assistance Strategy; World Bank 2002

Tracking o f Poverty Reducing Expenditure in the Framework o f the HIPC Initiative: Assessment and Action Plan, FAD and AFMMR, The World Bank and IMF 2001b

Mauritania-Focusing Public Expenditure on Growth and Poverty Reduction Public Expenditure Review The World Bank, PREM 4,2004

C. Other”

Politique Nationale de Santk et des Affaires Sociales 2005-2015, Ministkre de la Santk et des Affaires Sociales 2004

Politique Nationale de Ddveloppement de la Nutrition 2005-201 5, Ministkre de la Santk et des Affaires Sociales 2004

Rapport sur le recensement du personnel de la santk en Mauritanie, Ministkre de la Santk et des Affaires Sociales 2004

Rapport d ’exkcution et d’achkvement du projet d’appui au secteur de la santd, Ministkre de la Santk et des Affaires Sociales 2005

Enqukte Dkmographique et de Santk 2000-01 (Ofice National des Statistiques)

Santd et Pauvretk en Mauritanie: Analyse et Cadre Stratkgique de Lutte Contre La Pauvreti (Nouakchott, Mauritanie), MinistBre de la Santk et des Affaires Sociales; 2002

Plan Directeur de la Santk et des Affaires Sociales pour la Pkriode 1998-2002, Ministkre de la Santk et des Affaires Sociales; I997

Plan de Dkveloppement des Infrastructures Sanitaires, Ministkre de la Santk et des Affaires Sociales; 199 7

ONS (Ofice National de la Statistique), 2000, Mauritania: Demographic and Health Survey, (Nouakchott, Mauritania).

Politique Nationale de Santk et des Affaires Sociales 2005-2015, MOHSA 2004

’* Including electronic files

81

Politique Nationale de Ddveloppement de la Nutrition 2005-201 5, MOHSA, 2004

Rapport sur le recensement du personnel de la santd en Mauritanie, MinistBre de la Santd et des Affaires Sociales; 2004

Rapport d’exkcution et d’achBvement du projet d’appui au secteur de la santd, MinistBre de la Santd et des Affaires Sociales; 2005

Cadre de Politique de Relocalisation, MinistBre de la Santd et des Affaires Sociales; 2005

Plan National de Gestion des Ddchets Biomddicaux du Project d ’Appui h la Santk et ci: la Nutrition, MinistBre de la Santk et des Affaires Sociales; 2003

Plan de Gestion des Ddchets Biomkdicaux du Project Santd et h la Nutrition; 2005

Cadre de Gestion Environnementale et Sociale du Project Santd et Nutrition: 2005

82

Annex 13: Statement of Loans and Credits MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

Difference between expected and actual

disbursements Original Amount in US$ Millions

Project ID FY Puruose IBRD IDA SF GEF Cancel. Undisb. Oria. Frm. Rev’d

PO87 180

PO81368

PO78383

PO78368

PO7 188 1

PO71308 PO69095

PO66345

PO64570 PO447 1 1

PO55003

2005

2004

2004

2004

2002

2002

2002

2000

2000

2000

1999

M R Higher Education

MR: Community-Based Rural Development M R 2nd MINING SECTOR TA PROJECT

HIV/AIDS Multisector Control

M R Global Dist. Learning Center

MR-Edu Sec Dev APL (FY02)

M R Urban Development Program

MR EGYIWATEWSANITATION SECTOR REFORM TA M R CULTURAL HERITAGE

M R INTEG DEV PROG FOR IRRIGATED AGRIC MR-Nutr Food Sec & SOC Mobil LIL (FY99)

0.00 15.00 0.00 0.00 0.00 15.52 1.59 0.00 0.00 45.00 0.00 0.00 0.00 42.98 0.59 0.00

0.00 18.00 0.00 0.00 0.00 18.35 1.42 0.00 0.00 0.00 0.00 0.00 , 0.00 18.05 -1.88 0.00 0.00 3.30 0.00 0.00 0.00 1 .so 0.96 0.25 0.00 49.20 0.00 0.00 0.00 40.68 16.75 0.00 0.00 70.00 0.00 0.00 0.00 63.12 29.46 0.00 0.00 9.90 0.00 0.00 0.00 3.05 5.95 0.00

0.00 5.00 0.00 0.00 0.00 1.02 0.72 0.00 0.00 38.10 0.00 0.00 0.00 3.65 3.07 0.00

0.00 4.90 0.00 0.00 0.00 0.09 -0.00 -0.02 ,

Total: 0.00 258.40 0.00 0.00 0.00 208.31 58.63 0.23

MAURITANIA STATEMENT OF IFC’s

Held and Disbursed Portfolio In Millions o f U S Dollars

FY Auuroval Comuanv

~~

Committed Disbursed

IFC IFC

Loan Equity Quasi Partic. Loan Equity Quasi Partic

2000/04 GBM 5.00 0.00 5.00 0.00 5.00 0.00 5.00 0.00 PAL-Tiviski 0.46 0.00 0.00 0.00 0.46 0.00 0.00 0.00

Total portfolio: 5.46 0.00 5.00 0.00 5.46 0.00 5.00 0.00

Approvals Pending Commitment

FY Approval Company Loan Equity Quasi Partic.

Total pending commitment: 0.00 0.00 0.00 0.00

83

Annex 14: Country at a Glance MAURITANIA: HEALTH AND NUTRITION SUPPORT PROJECT

POVERTY a d SOCWL M autania

2004 Powlation. mid-war Im,#bnsl GNI per capita fAtksme#iQd. US1 GNI IALsmettmd. Us% b%ml Averaae amml amth, 199804

Powlation a1 labor hme f%l

KEY ECONOMIC RATIOS a d LONG-TERM TRENDS 1984

GOP IUS% b,#bnsl Goss capital fonnationlGOP marts ofgoodsand 5eniceslGDP Go55 domestic saunadGDP Gossnaiional sunaslGDP

0 83 21 3 39 7 -2 7

0.1rrent actourt balancelGDP hterest ~emnts lGDP Totd deWGDP Totd debt ~ r v i c e l s r ~ o r k Presentwlue ofdebtlGDP Present wlue ofdebtkwpcrts

-26.1 43

1585 20.1

198494 199404 Lveraue anxralom&l GO P 2.2 48 GO P Der carrita 0.0 2 3 b o @ of aoods and senices -2.1 -3.1

2 7 570 1 8

2.4 3 2

46 62 54 87 30 35 41 88 89 85

1994

1D 20.7 42 D 189 21 2 -3 8 7 0

2165 22 2

2003

6.4 3 8

-9 5

Sub Saharan

Africa

719 600 432

2 2 1D

37 46

101

58 65 95

102 88

2003

1 3 195 268 21 3

5 A -18D

1.1 1338 26 S 485

1313

2004

89 4 3 85

LOW- inccme

2338 510

1,184

1 8 2.1

31 58 79 44 75 81 9 4

101 88

2004

1 5 21 5 29.4 25.4 19.4

-35 8 09

1233 21D 41.1

1048

2UId-08

118 9 2

539

3eveloprn ent diamond

Life e g e m n c v

GNI GPXS Der primary :apb enrollment

1 k e s s t c impmued water source

BGnornlc radar"

Trade

Indebtedness

STRUCTURE of the ECON 0 MY 1984 1994 2003 2004

d ofGW1 klricutlure 288 27D 20D 183 hdustru 25.4 31.1 30.4 338

hhnukiurina 118 102 10.1 S Q M e S 46D 419 498 48.1

Husehold inal mngmobon emendriure 7 5 8 668 630 59.7 General aoJt inal mnsJmdon emendriure 2 7 1 185 15.7 149 b ~ f t ~ of amds and semces 63.7 468 639 69.7

Lveraoe arnxra/oRl&71 hicutlure hdustru

SeMces

kusehold inal congmdon emendimre General gout fnal conamption emendhre Goss capital formation trports of gmds and services

h& n u kiu ri n a

198494

3 3 2 8 OD 3 5

42 -32 -42 -5 2

199404

1 3 2 5 -65 7 9

49 7 2 8 5 4.7

2003 2004

6D -2 7 5 8 5 8 6 8 6 3 6 8 105

22 2 7D 3 8 8.4

-108 8 3 10.1 9 8

M e : 2004 daa are prelirrinarqesrimtrs. me damonds show bur kevindicators in the muntwfin boldlcompared w ith its inmme-amup auerarie. ldata are missina,?4w diamond will be incomplete.

84

PRICES and GOVERNMENT FINRNCE

Domestk &ices Rchamrl Consumer prices holicit GDP delator

mof GDP. inoh'escwrerff m&I Cumnt revenue hmnt budaet balance Owrall sJmlusldeicit

G W W M R t f i R a R C e

TRADE

{US$ aMns1 Total expcrts (fob1

h n ore Fish h4nuCmres

Total impcrts Ian Food Fuel and enemv Capbl goods

b o r t price index 1ZOQO=?OO) hpor t price index 12OQO=WQI Terms oftrade f 2 Q O Q = f Q O I

BAUNCEaf PAYMENTS

IUS% a M n d h O r l 5 of aocds and seruicos hoorts of aoods and seru'ces Resourn balance Na income Net currentnansfxs Current acwunt balance Financina items (net) Changes in net resems Mm: Resenes including gold {US$ d h R 5 ) Conversion a (D€Ca bcad/US$I

EXTERNAL DEBTand RESOURCE FLOWS

fuss S#hRSl TMal debt outsiandina and disbursed

IBRD IDA

IBRD IDA

Offiaal grants Official creditors Private credtors Foreign dire& investnent (net inflows] Portfolio equitvInet inlowsl

World Bank program Commhents Dsbumments Principal repav-nents Net flows hteeasipavnents Nettransfers

Total debt seruice

Comoosition of net resource flows

1984

10.9

1984

299 144 148

302 76 43 85

1984

322 480

-158 -39 86

-218 211

6

81 63 B

1984

1322 49 55 67

7 0

77 20 9 0

0 5 3 2 4

-2

1994

4.1 62

24.7 6.7

-3.1

1994

393 163 207

328 95 36 73

115 101 114

1994

431 470 -39 -53 55

-37 26 11

44 1236

1994

2223 13

30 1 102

9 3

0 2

20 35 9

26 3

23

2003

4.6 9.2

29.5 -10.2 -10.2

2003

303 172 145

564 110 125 61

104 1 00 105

2003

328 753

-425 66

117 -239

32 265.0

2003

1.780

545 126

0 10

86 0

214

0 42 6

36 4

32

2004

10.4 7.9

29.2 -2.6 -2.6

2004

408 193 148

925 114 122 68

107 100 107

2004

429 1.196 -767 101 121

-545

39 265.6

2004

1.887

5# 126

D 10

0 242

0 42

6 37

4 33

I -GDP rkllabr - P I I

E:pGrt and I niport 18 .+el I IU st m 111. I I

Current accuunt balance b-, GDP fii ,.

Development Economics 414106

85